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College  of  ^fjpsficiang  an&  ^urgeonfi 

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THE 

JOHNS  HOPKINS  HOSPITAL 
REPORTS 


THE 


Johns  Hopkins  Hospital 


Reports 


STUDIES  ON  HYPERTROPHY  AND  CANCER 
OF  THE  PROSTATE 


VOLUME   XIV 


BALTIMORE 

The    Johns   Hopkins    Press 

1906 


'?? 


/'/ 


Copyright,    1906,  by 
THE  JOHNS  HOPKINS  PRESS 


BALTIMORE,    MD.,    U.   S.  A. 


CONTENTS 


I.  The  Treatment  of  Prostatic  Hypertrophy  by  Conservative  Peri- 
neal Prostatectomy.  An  Analysis  of  Cases  and  Results  based 
on  a  Detailed  Report  of  145  Cases.     By  Hugh  H.  Youxg,  M.  D.  .       1 

II.     Recto-Urethral  Fistulge.     Description  of  New  Procedures  for  their 

Prevention  and  Cure.     By  HroH  H.  Young,  M.  D 477 

III.  The  Early  Diagnosis  and  Radical  Cure  of  Carcinoma  of  the  Pros- 
tate. Being  a  Study  of  40  Cases  and  Presentation  of  a  Radical 
Operation  which  was  Carried  Out  in  Four  Cases,  and  an 
Appendix,  Compiled  Later,  Containing  the  Complete  Histories 
of  64  Cases.    By  Hugh  H.  Yovsg,  M.  D 485 


ILLUSTRATIONS 


1.  Large    intravesical    median    lobe    removed    by    suprapubic    route 

(Fig.  1)    7 

2.  Instrument  completed   (Figs.  2  and  3) 10 

3.  Longitudinal  section  of  normal  prostate   (Fig.  4) 11 

4.  Cross-section  of  normal  prostate   (Fig.  5) 12 

5.  Longitudinal  section  of  a  prostate,  with  great  hypertrophy  of  the 

median  and  lateral  lobes   (Fig.  6) 13 

6.  Six  cross-sections  of  the  same  prostate  at  different  levels,  as  in 

Fig.   5    (Fig.   7) 14 

7.  Side   view   of  hypertrophied   prostate,   showing   low   entrance   of 

ducts  on  posterior  surface  (Fig.  8) 15 

8.  The  inverted  V  cutaneous  incision   (Fig.  9) 16 

9.  Exposure  of  bulb,  central  tendon,  and  levatores  ani  (Fig.  10)  ... .  17 

10.  Bifid  retractor   (Fig.  11) 18 

11.  Bifid  retractor.     Side  view   (Fig.  12) 18 

12.  Showing  bifid  retractor,  exposing  and  making  tension  on  the  cen- 

tral tendon    (Fig.  13) 19 

13.  Opening    of    urethra    on    sound,    preparatory    to    introduction    of 

tractor    (Fig.    14) 20 

14.  Tractor  introduced    ( Fig.   15 ) 21 

15.  Showing   position   of   blades    in    interior    of   bladder    in    case   of 

median  and  bilateral  hypertrophy   (Fig.  16) 22 

16.  Posterior  retractor  (Fig.  17) 23 

17.  One  of  the  lateral  retractors   (Fig.  18) 23 

18.  Blunt  dissectors  or  enucleators  (Fig.  19) 23 

19.  External  enucleation  begun   (Fig.  20) 24 

20.  Lobe  forceps    (Fig.  21) 25 

21.  Enucleation  of  lobes.     Forceps  in  position  (Fig.  22) 26 

22.  Two  lobes  removed  by  perineal  prostatectomy  (Fig.  22a) 26 

23.  Schematic  cross-section  after  enucleation  of  lateral  lobes,  show- 

ing ducts  and  median  bridge  of  tissue  (Fig.  23) 27 

24.  The  blade  rotated  so  as  to  engage  middle  lobe  (Fig.  24) 27 

25.  Showing  technique  of  delivery  of  middle  lobe  into  cavity  of  left 

lateral  lobe   (Fig.  25) 28 

26.  Photograph  of  a  pedunculated  median  lobe  which  was  removed 

through  the  cavity  left  by  left  lateral  lobe  without  tearing 

urethral  or  vesical  mucosa   (Fig.  2oa) 29 

27.  Photograph  of  prostate  in  which  the  left  and  median  lobes  were 

enucleated  in  one  piece    (Fig.  26) 30 


viii  Illustrations. 

28.  Longitudinal   section   after   enucleation  of   median   lobe   through 

a  lateral  cavity   ( Fig.  27 ) 30 

29.  Cross-section  at  level  of  cavity  left  by  median  lobe  (Fig.  28)....  30 

30.  Blade  engaging  anterior  lobe    (Fig.  29) 31 

31.  The  use  of  index  finger  to  deliver  a  small  median  lobe  into  lateral 

cavity    (Fig.  30) 32 

32.  Showing  suburethral  method  of  enucleating  median  bar  (Fig.  31)     34 

33.  Schematic  longitudinal  section  of  the  urethra,  showing  the  me- 

dian enlargement  enucleated  beneath  the  urethra  (Fig.  32)  . .     34 

34.  Photograph,  natural  size,  of  a  small  median  bar  (Fig.  33) 35 

35.  Division  of  lateral  wall  of  urethra  to  allow  extraction  of  large 

calculus  through  left  lateral  cavity   (Fig.  34) 36 

36.  Exact     size     of     calculus     removed     through     perineal     incision 

(Fig.  35)    37 

37.  Showing  how  the  tractor  may  slip  beneath  prominent  lateral  lobes 

(Fig.    36)     38 

38.  Scheme  of  continuous  irrigation  apparatus  (Fig.  37) 39 

39.  Approximation  of  levator  ani  muscles  with  single  suture  of  cat- 

gut (Fig.  38)    40 

40.  Final   closure    (Fig.    39) 42 

41.  Gimlet  curette   (Fig.  39') 101 

42.  A  picture  commonly  seen  in  the  glandular  form  of  hypertrophy 

(Fig.   A)    126 

43.  Epithelial   activity   in   one   of  the   acini   shown,   has   resulted   in 

the  formation  of  capillary  loops   (Fig.  B) 127 

44.  A  very  glandular  form  of  hypertrophy   (Fig.  C) 128 

45.  A  high  magnification  of  portion  of  the  field  shown  in  C  (Fig.  D) .   129 

46.  In  the  center  is  seen  a  rather  extensive  degree  of  cystic  dilata- 

tion of  numerous  acini   (Fig.  E) 130 

47.  A  section  from  the  periphery  of  a  hypertrophied  lobule  showing 

the  condensation  of  the  tissue  and  the  flattened  and  elongated 
acini  (Fig.  F)    131 

48.  Represents  a  fibro-muscular  form  of  hypertrophy  (Fig.  G) 132 

49.  A  cross-section  of  a  prostate  which  represents  an  early  stage  of 

hypertrophy  (Fig.  H)    135 

50.  A  cross-section  of  a  hypertrophy  somewhat  more  advanced  than 

that  seen  in  Fig.  H   (Fig.  I) 135 

51.  The  hypertrophy  here  is  advanced  still  further  than  that  seen  in 

Figs.  H  and  I  (Fig.  J) 136 

52.  A  myomatous  nodule  (Fig.  K) 137 

53.  Single-bladed  tractor    (Fig.    39a) 143 

54.  Lateral  lobes,  median  bar,  and  floor  of  urethra  removed  in  one 

piece   (Fig.  40)    143 

55.  Single-blade  prostatic  tractor   (Fig.  40a) 150 

56.  Large  lateral  and  median  lobes    (Fig.  41) 170 


Illustrations.  ix 

57.  Lateral    lobes,    moderate    median    bar,    small    pedunculated    sub- 

cervical  median  lobe   (Fig.  42) 200 

58.  Long  pedunculated  median  lobe,  moderate  lateral  lobes  (Fig.  43)  .  269 

59.  Case  64   (Fig.  44) 287 

60.  Large  lateral  lobes,  each  with  a  portion  of  median  lobe  attached 

(Fig.    45)     289 

6L  Case  74   (Fig.  46)    309 

62.  Median  bar,  oral  suburethral  lobe,  two  lateral  lobes   (Fig.  47)..   312 

63.  Case  104   (Fig.  48) 375 

64.  Large  coalescent  median  and  lateral  lobes   (Fig.  49) 388 

65.  Case  121    (Fig.  50) 416 

66.  Large  median  and  lateral  lobes  (Fig.  51) 420 

67.  Very  small  median  and  lateral  lobes,  causing  complete  retention 

of  urine    (Fig.  52) 426 

68.  Case  126    (Fig.  53) 428 

69.  Case  127  (Fig.  54) 432 

70.  Case  137  (Fig.  55) 454 

71.  Small  median  and  lateral  lobes  from  man,  age  37  (Fig.  56) 455 

72.  Large  globular  median  lobe,  moderate-sized  lateral  lobes  (Fig.  57)  468 

73.  To  show  levator  muscles  (Fig.  1) 481 

74.  After  transverse  section  of  urethra  (Fig.  1) 499 

75.  Exposure  of  the  seminal  vesicles  (Fig.  2) 500 

76.  Incision  into  bladder  just  above  prostate  (Fig.  3) 501 

77.  Exposure  and  division  of  trigone   (Fig.  4) 502 

78.  Final  separation  of  seminal  vesicles  and  division  of  vasa  (Fig.  5)  503 

79.  Photograph  of  specimen,  side  view  (Fig.  6) 504 

80.  Photograph  of  posterior  view  of  specimen  (Fig.  7) 504 

81.  The  anastomosis  of  anterior  wall  of  bladder  to  urethra  has  been 

made.     The  rest  of  vesical  opening  is  being  closed  (Fig.  8)  .   505 

82.  Diagram  showing  plan  of  vesico-urethral  anastomosis   (Fig.  9)..   506 

83.  Lateral  view  of  specimen  from  Case  VIII.     Case  11,  side  view 

prostate  and  vesicle  (Fig.  10) 513 

84.  Anterior  view,   showing  trigone,  urethral   orifice,  the   vasa,   and 

prostate    ( Fig.   11 ) 515 

85.  Schirrous  form  of  adenocarcinoma.     Case  13a  (Fig.  12) 528 

86.  A   medullary  form   of   carcinoma   in   which  there   is   very   little 

stroma  and  the  cancer  cells  varying  in  size  and  shape  are 
loosely  arranged.     Case  64    (Fig.   13) 529 

87.  A  tubular  form  of  carcinoma  in  which  solid  strands  of  epithelial 

cells  are  seen  growing  into  the  lumina  of  the  tubules  and  by 
their  union  forming  irregular  open  spaces.  Case  10 
(Fig.  14) 530 

88.  Nests  of  cancer  cells  lying  in  between  dense  bundles  of  muscle. 

Case  10   (Fig.  15) 531 


X  Illustrations. 

89.  A  small  carcinoma  nodule  about  2  mm.  in  diameter  in  an  other- 

wise benign  prostate.     Some  of  the  normal  acini  still  persist 

in  the  cancerous  area.     Case  9    (Fig.  16) 532 

90.  Shows  an  acinus  partly  lined  by  cancer  cells  and  partly  by  normal 

epithelium.     Case  14    (Fig.  17) 533 

91.  Cystoscopic  chart  before  operation.     Case  10  (Fig.  18) 560 

92.  Cystoscopy    one    year    after    perineal    prostatectomy.      Case    10 

(Fig.    19)     562 

93.  Prostate  and  region  of  seminal  vesicles  (Fig.  20) 604 

94.  Outlines  of  induration  in  region  of  prostate,  seminal  vesicles,  and 

intervesicular  space.     Case  53    (Fig.  21) 613 

95.  Shape  of  the  prostate  and  indurated  vesicle.     Case  56  (Fig.  22)  .  .   617 

96.  Rectal  chart  with  outlines  of  prostate,  vesicles,  lymphatics,  and 

pelvic  glands  shown  in  comparison  with  normal   (in  dotted 
lines).    Case  60  (Fig.  23) ^T6 

97.  Cystoscopic  chart  showing  irregular  tumor  growth  around  pros- 

tate orifice.     Case  61   (Fig.  24) 625 


STUDIES  ON  HYPERTROPHY  AND  CANCER 
OF  THE  PROSTATE 


BY 


HUGH  H.  YOUNG 

Associate  Professor  of  Genito-Urinary  Surgery, 

The  Johns  Hopkins  University 


THE  TREATMENT  OP  PROSTATIC  HYPERTROPHY  BY 
CONSERVATIVE   PERINEAL  PROSTATECTOMY. 

AN  ANALYSIS  OF  CASES  AND  RESULTS  BASED  ON  A  DETAILED 
REPORT  OF  145  CASES. 

By  HUGH   H.  YOUNG,  M.  D. 

CONTENTS. 

I.  Peeface:   Misleading  Statements  and  Statistics  in  the  Liter- 
ature   2 

II.  The  Operation  of  Conservative  Perineal  Prostatectomy 6 

III.  An  Analysis  of  145  Cases  of  Perineal  Prostatectomy 43 

a.  Onset  of  the  disease 47 

b.  Status  prsesens   54 

Symptoms      54 

Sexual  powers   58 

Catheter  life    58 

Condition  of  patient    61 

Character  of  prostatic  enlargement   64 

Cystoscopic   findings    71 

c.  Preliminary  treatment  77 

d.  The  operation  81 

Character  of  technique   81 

Shock  of  operation;    spinal  anaesthesia 85-86 

Characteristics  of  lobes  removed  87 

Operation  in  the  presence  of  vesical  calculi 92 

e.  The  convalescence   93 

Complications     95 

Length  of  time  in  hospital   98 

f.  Immediate  result.     Condition  on  discharge  101 

g.  Condition  after  leaving  hospital    108 

h.  Contracture  of  bladder  before  and  after  operation 110 

i.  Ultimate  results    113 

Mortality      113 

The  removal  of  obstruction  116 

Perineal  fistulse    118 

Frequency  of  urination  due  to  vesical  contracture  ....   118 

Cases  now  suggesting  presence  of  calculi  118 

Cases  with  peculiar  symptoms  119 


Hugh  H.  Young. 


Recto-urethral  fistulse    120 

Incontinence  of  urine   120 

Pain    121 

Preservation  of  sexual  powers   122 

j.  The  pathology,  as  shown  by  a  study  of  120  cases 124 

fc.  Conclusions 140 

PREFACE. 

I.    Misleading  Statements  and  Statistics  in  the  Literature. 

The  following  paper  is  the  result  of  numerous  articles  which  have 
appeared  recently,  demanding  more  detailed  information  as  to  the  pre- 
and  post-operative  condition  of  patients  on  whom  perineal  prostatec- 
tomy has  been  performed. 

The  promulgation  of  successful  methods  of  removing  hypertrophied 
prostates,  and  the  assertion  of  their  benignity  has  been  followed  by 
their  wholesale  employment  by  men  unprepared  to  do  these  operations, 
and  as  a  result  a  considerable  mortality  has  been  produced  and  many 
of  the  operative  results  have  been  imsatisf  actory. 

Many  physicians  without  special  operative  training,  doing  a  surgical 
operation  only  now  and  then,  without  the  requisite  knowledge  of  the 
rather  intricate  anatomy  of  the  perineum,  and  the  pathology  and 
mechanics  of  the  prostatic  obstructions,  have  boldly  essayed  to  operate 
these  cases  and  as  a  result  a  frightful  mortality  and  a  horrible  record 
as  to  results  and  complications  has  been  recorded  against  a  benign 
and  thoroughly  successful  procedure. 

It  is  not  surprising  then  that  Whiteside  finds  a  mortality  of  20% 
in  36  cases  reported  by  nine  operators,  and  absolutely  good  results  in 
only  30%  of  the  cases,  and  that  Belfield  and  Pedersen  after  making 
similar  studies  shoidd  send  out  "  timely  "  warnings  against  prostatec- 
tomy as  a  routine  procedure,  and  that  we  should  hear  of  "  a  return  to 
conservative  methods,^'  non-operative  treatment,  the  catheter  life  (with 
all  its  horrors!),  and  the  "selection  of  cases"  which  are  suitable  for 
operation. 

If  the  reaction  against  operation  which  has  been  aroused  (for  the 
pendulum  once  started  backward  must  continue  its  swing)  results  in 
discouraging  men  imprepared  to  do  good  work  in  this  line,  men  who 
cannot  use  and  decry  the  using  of  the  cystoscope  and  ignorantly  neg- 
lect to  take  advantage  of  its  often  great  assistance,  and  who  rush  in 


study  of  145  Cases  of  'Perineal  Prostatectomy.  3 

blindly  without  knowing,  seeing  or  apparently  caring  what  they  are 
doing,  much  will  be  gained.  But  if  the  medical  profession  is  unduly 
alarmed  and,  returning  to  the  old  so-called  conservative  methods  rele- 
gates such  patients  to  miserable  catheter  lives,  and  refuses  them  the 
splendid  results  obtainable  by  accurate  methods,  much  will  be  lost. 

Such  is  the  history  of  all  advances  in  surgery — first  the  demonstra- 
tion of  valuable  new  procedures,  then  a  horde  of  bungled  operations, 
then  a  discovery  of  miserable  results  and  a  startling  mortality,  then  a 
reaction  against  the  procedure,  and  finally,  but  after  the  loss  of  many 
valuable  years,  a  return  to  the  truth. 

When  one  has  had  during  the  past  year  50  consecutive  operations, 
with  but  one  immediate  or  remote  death  (and  this  patient  in  extremis 
at  time  of  operation),  with  no  complications  of  the  slightest  moment, 
and  no  bad  results  it  is  not  wonderful  that  he  feels  outraged  by  the 
presentation  of  a  mortality  of  30%  and  successful  results  in  only  30% 
in  36  cases  operated  on  by  nine  surgeons ! 

There  have  also  been  those  of  experience  and  knowledge,  but  cham- 
pions of  the  suprapubic  route,  who  have  savagely  attacked  perineal, 
prostatectomy  (without  having  tried  the  procedure). 

For  example,  in  the  Transactions  of  the  Medical  Society  of  London 
for  May  8,  1905  (Vol.  XXVIII),  in  a  discussion  on  "The  Perineal 
and  Suprapubic  Methods  of  Prostatectomy,"  one  of  the  members  is 
reported  to  have  thus  delivered  himself: 

"  Mr.  P.  J.  Freyer  remarked  that  he  had  not  come  either  to  read  a  paper 
or  to  make  a  speech  on  the  subject,  as  his  views  with  reference  to  removal 
of  the  prostate  had  already  been  placed  before  the  Profession  in  numerous 
lectures  and  papers  which  had  been  published  in  the  journals  during  the 
last  four  years.  He  congratulated  the  Society  that  it  had  awakened  from 
what  appeared  to  be  a  lethargy  with  regard  to  the  great  subject  of 
removal  of  the  prostate.  It  seemed  extraordinary  that  during  the  past 
four  years,  when  the  subject  had  been  so  much  discussed,  the  oldest 
medical  society  in  London  should  not  have  hitherto  invited  discussion  upon 
it.  He  thanked  his  old  friend  and  colleague,  Mr.  Harrison,  for  the 
full-hearted  eulogium  which  he  had  been  good  enough  to  pronounce  upon 
his  (Mr.  Freyer 's)  operation,  which  was  all  the  more  gratifying  as  Mr. 
Harrison's  views  in  that  respect  had  been  a  plant  of  slow  growth.  When 
first  introduced  to  the  Profession  the  operation  was  not  fully  grasped  by 
Mr.  Harrison,  who  did  not  believe  in  its  efficacy.  With  reference  to  the 
subject  of  perineal  and  suprapubic  prostatectomy,  he  remarked  that  there 
was  no  comparison  whatever  capable  of  being  introduced  between  the 
two  operations,  because  they  did  not  deal  with  the  same  subject.     It  was 


6  Hugh  H.  Young. 

In  this  report  I  have  not  given  the  details  of  five  cases  in  which 
perineal  prostatectomy  was  performed  thinking  that  the  prostate  was 
benign  when  subsequent  examination  showed  that  it  was  malignant, 
six  cases  which  were  under  my  care  but  were  turned  over  to  assistants 
(the  operation  being  partly  performed  by  me),  three  cases  of  perineal 
prostatectomy  done  without  the  tractor,  and  four  cases  of  perineal 
prostatectomy  for  chronic  prostatitis.  Most  of  these  cases  will  be 
found  reported  in  more  or  less  complete  detail  in  other  portions  of 
this  volume,  in  the  articles  on  carcinoma  and  prostatitis.  There  were 
no  cases  of  rectal  fistula,  or  other  bad  results  among  them  so  that 
nothing  is  being  concealed.  The  present  study  of  cases  is  intended  to 
include  only  those  operated  by  a  special  technique  and  of  a  benign 
hypertrophic  character. 

II.    The  Operation  of  Conservative  Perineal  Prostatectomy. 

In  several  publications  which  have  appeared  at  intervals  during  the 
past  four  years,  I  have  described  a  so-called  method  of  conservative 
perineal  prostatectomy  and  reported  lists  of  cases. 

The  development  of  the  operation  and  the  reasons  for  the  various 
improvements  were  described  as  follows  in  my  first  publication  in  the 
Journal  of  the  American  Medical  Association,^  October  24,  1903. 

The  literature  of  the  prostate  and  its  operative  treatment  has  be- 
come so  vast  that  I  vsdll  not  attempt  to  discuss  the  many  valuable 
articles  which  bear  on  this  subject,  but  will  simply  present  a  resume 
of  my  own  work  and  the  problems  which  have  presented  themselves. 

My  first  prostatectomy  was  in  1S98,  a  patient  on  whom  a  supra- 
pubic opening  had  been  made  for  drainage.     At  this  operation  a  tre- 

^  The  use  of  a  new  tractor  for  perineal  prostatectomy  was  first  described 
in  a  discussion  at  a  meeting  of  ttie  Southern  Surgical  and  Gynecological 
Association,  on  November  12,  1902;  a  second  report  was  made  and  a 
perfected  technique  by  which  the  ejaculatory  ducts  were  preserved,  de- 
scribed at  a  meeting  of  the  Medical  and  Chirurgical  Faculty  of  Maryland 
in  April,  1903.  A  more  complete  report  was  made  before  the  American 
Association  of  Genito-Urinary  Surgeons,  May  12,  1903,  and  was  published 
in  the  Journal  of  the  American  Medical  Association,  October  24,  1903. 

Since  then  additional  reports  have  been  made  in  the  Monatsberichte  fiir 
Urologie,  Bd.  IX,  Heft  5  u.  6,  1904.  Journal  of  the  American  Medical 
Association,  October  4,  1903.  The  Annals  of  Surgery,  April,  1905,  and  the 
Journal  of  the  American  Medical  Association,  1905. 


study  of  IJj-o  Cases  of  Perineal  Prostatectomy.  7 

mendous  intravesical  outgrovrth  of  the  middle  lobe  "^as  found,  and  as 
there  was  Terr  little  enlargement  of  the  lateral  lobes,  I  enucleat-ed 
the  mass  through  the  suprapubic  -wound,  with  the  assistance  of  a  finger 
in  the  rectum  (Fig.  1),  a  method  which  has  also  been  employed  by 
Guiteras,  and  described  bv  him  in  1900. 


Y^> 


9^ 


Fig.  1. — A  large  intravesical  median  lobe  removed  by  suprapubic  route. 
Actual  size. 


The  next  three  cases  presented  no  median  enlargements,  the  hyper- 
trophy being  confined  to  the  lateral  lobes.  Following  the  advice  of 
Alexander,  I  used  the  combined  method,  removing  the  lobes  through 
the  perineal  wound  with  the  assistance  of  a  suprapubic  incision, 
illthough  the  operation  was  tedious  and  extensive,  these  patients  did 
well,  and  in  a  paper  on  the  subject  I  said  that  Alexanders  was  the 
operation  of  choice,  except  for  middle  lobe  cases. 


8  Hugh  H.  Young. 

My  next  four  cases  were  characterized  by  considerable  middle  lobe 
enlargements,  and  I  therefore  used  the  suprapubic  route,  and  was  sur- 
prised to  find  that  with  the  assistance  of  the  finger  in  the  rectum  I 
could  easily  enucleate  very  large  lateral  lobes  in  one  piece  with  the 
median  without  destroying  the  urethra.  The  operation  was  also  very 
much  quicker — it  frequently  being  possible  to  complete  the  enucleation 
in  five  to  six  minutes,  whereas  the  combined  operation  would  fre- 
quently take  nearly  an  hour. 

The  principal  objection  to  the  perineal  route  was  the  necessity  of  the 
suprapubic  incision  to  push  the  prostate  down  into  the  perineum 
where  it  could  be  enucleated,  and  I  then  thought  of  having  an  instru- 
ment made  with  two  blades  which  could  be  inserted  closed  through  a 
perineal  urethrotomy,  separated  when  in  the  bladder,  and  then  used  as 
a  tractor  to  drag  the  prostate  toward  the  perineum.  This  was  in  1899, 
but  I  never  had  the  instrument  constructed,  but  continued  to  do  all 
prostatectomies  suprapubically.  The  results  obtained  were  excellent, 
the  greatest  objection  being  the  considerable  hemorrhage  following 
the  operation,  the  great  duration  of  the  convalescence  and  the  occa- 
sional development  of  suprapubic  hernia  afterward. 

In  1899  several  patients  came  to  me  who  were  so  old  and  so  weak 
that  I  was  afraid  to  even  administer  a  general  anesthetic,  much  less 
to  do  so  severe  an  operation  as  a  suprapubic  prostatectomy.  One 
patient  being  unable  to  use  a  catheter,  caused  me  to  purchase  a  Bot- 
tini  incisor,  and  the  results  which  I  obtained  on  extremely  old  and 
feeble  men,  under  local  cocaine  ansesthesia,  were  indeed  so  marvellous 
that  I  adopted  the  Bottini  operation  as  the  method  of  choice  in  cases 
past  65  years  of  age,  who  were  not  in  a  prime  surgical  condition. 
Using  my  instrument  with  interchangeable  blades  of  different  size  I 
was  able  to  operate  safely  and  radically  on  prostates  of  any  size.  I 
found  it  possible  also  to  successfully  attack  large  middle  lobes  by 
making  an  oblique  incision  with  the  cautery  blade  on  each  side  of  the 
pedicle,  thus  dropping  it  back  out  of  the  way,  where  it  would  after- 
ward atrophy.  In  two  years  I  operated  thus  on  40  cases,  with  two 
deaths,  only  one  of  which  was  due  to  the  operation.  Of  these  15  were 
over  70  and  three  over  80,  with  no  deaths,  and  with  cures  in  all 
these  cases  but  one. 

I  feel  sure  that  many  of  these  patients  would  have  succumbed  had 
a  suprapubic  or  a  combined  prostatectomy  under  general  anaesthesia 
been  done,  with  the  subsequent  prolonged  recumbent  posture.     The 


study  of  Ho  Cases  of  'Perineal  Prostatectomy.  9 

use  of  cocaine,  the  little  shock  and  hemorrhage  produced  by  the  Bot- 
tini,  and  the  rapidity  of  the  convalescence — out  of  bed  on  the  second 
or  third  day — ^were  the  factors  which  contributed  to  save  them. 
Since  then  I  have  used  the  cautery  incisions  on  many  more  cases, 
some  just  as  old  and  as  desperate  as  those  described  above,  with  similar 
gratifying  results. 

The  publications  of  S}Tns,  Murphy,  Ferguson,  Bryson,  and  others 
within  the  past  two  years,  caused  me  to  turn  my  attention  again  to  the 
perineal  route.  In  studying  the  methods  that  have  been  proposed, 
the  intravesical  balloon,  which  Syms  used  to  draw  the  prostate  into 
the  perineal  wound,  seemed  to  me  to  be  much  better  suited  to  over- 
come the  great  objection  to  perineal  prostatectomy,  the  depth  of  the 
wound  with  the  consequent  difficulty  of  reaching  the  lobes  to  enucle- 
ate them,  than  MurpM^s  hooks,  Ferguson's  capsular  retractors,  or 
Bryson's  suprapubic  prevesical  incision. 

The  rubber  balloon  did  not,  however,  appear  to  me  to  be  quite  per- 
fect in  that  it  did  not  seem  to  furnish  sufficient  strength  for  the  great 
traction  which  is  necessary,  and  the  fact  that  S}Tns  had  acknowledged 
that  he  found  a  metal  instrument  devised  by  Gouley,  which  was  passed 
like  a  sound  into  the  bladder,  of  great  assistance  in  pushing  down  the 
prostate,  confirmed  me  in  my  opinion  that  while  the  idea  of  making 
traction  by  means  of  an  instrument  which  could  be  introduced  into 
the  bladder  through  a  perineal  urethrotomy  wound  was  correct,  the 
method  adopted  by  Syms — the  rubber  balloon  and  the  tube— could 
be  improved  on. 

I  therefore  set  to  work  to  construct  an  instrument  of  metal  for  this 
purpose.  After  several  months  of  experiment,  during  which  I  en- 
deavored to  discover  and  correct  the  faults  of  each  model  ^  by  operative 
use,  the  instrument  was  completed,  as  shown  in  Illustrations  2  and  3. 
It  consists  of  two  fenestrated  blades  attached  to  shafts,  one  of 
which  revolves  around  the  other.  When  the  two  handles  near  the 
outer  end  which  regulate  the  rotation  are  brought  together  the  blades 
are  approximated  and  in  position  for  insertion  into  the  bladder 
through  the  opening  in  the  membranous  urethra  (Fig.  2).  Once  intro- 
duced above  the  intravesical  limits  of  the  prostatic  lobes  the  blades  may 
be  separated  by  rotating  the  handles  away  from  each  other  (Fig.  3), 

A 
^  See  Appendix,  Case  1,  p.  143,  for  description  of  first  instrument  used 
and  p.  150  for  the  second  modification. 


10 


Hugh  H.  Young. 


when  it  is  ready  for  whatever  traction  on  its  shaft  may  be  necessary 
to  draw  the  prostate  well  into  the  perineal  wound.  Before  discussing 
the  use  of  this  instrument,  however,  I  wish  to  discuss  some  problems 
of  technic  and  conservatism  which  have  been  met. 

The  ejaculatory  ducts. — The  fact  that  many  of  the  cases  requiring 
prostatectomy  are  vigorous  men  in  the  fifties,  with  sexual  powers  well 
preserved,  renders  it  important  to  do  nothing  to  injure  their  manly 
vigor. 


Fig.   2. — The  prostatic  "  tractor  "   closed,  ready  for  introduction. 


Fig.  3. — The  prostatic  tractor  opened  out. 

In  a  recent  report.  Petit  ^  furnishes  the  results  of  a  careful  study 
of  Albarran's  cases  of  perineal  prostatectomy.  He  was  able  to  fol- 
low six  cases  who  had  had  normal  sexual  powers  before  the  operation. 
Of  these,  two,  both  under  60  years  of  age,  have  never  been  able  to  have 
erections  since  the  operation.  In  two  cases  the  erections  are  much  en- 
feebled; two  cases  are  as  strong  sexually  as  before  operation. 

The  operation  is  performed  by  Albarran  without  respect  to  the 
ejaculatory  ducts,  the  prostatic  urethra  being  opened  widely  in  the 
median  line,  and  the  lobes  enucleated  through  this  incision.  It  would 
seem  that  the  ejaculatory  ducts  are  almost  certain  to  be  injured  or 
removed  in  this  procedure. 


^  Petit:  De  la  Prostatectomie  Perineale,  Paris,  1902. 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  11 

Petit  mentions  the  work  of  other  operators  and  concludes :  "  It 
seems  to  be  shown  that  perineal  prostatectomy  diminishes  if  it  does 
not  suppress  erections  in  some  cases.  But  it  is  a  curious  fact  that 
some  cases  operated  on  can  still  ejaculate."  Another  evidence  of  in- 
Jury  done  to  the  ejaculatory  ducts  is  that  Petit  reports  that  12  cases 
in  30  suffered  with  epididymitis  after  the  operation. 

I  know  of  no  other  statistics  on  these  points.  The  three  cases  on 
whom  I  performed  perineal  prostatectomy  by  Alexander's  method 
five  years  ago  I  have  been  unable  to  follow,  and  the  twelve  perineal 
prostatectomies  which  I  have  done  in  the  past  five  months  are  too 
recent  to  draw  final  deductions  from.  Although  the  question  needs 
further  study,  it  is  nevertheless  evident  that  due  attention  should  be 
paid,  in  performing  the  operation,  to  the  importance  of  the  prostate 
as  a  sexual  organ. 


Fig.  4. — Longitudinal  section  of  normal  prostate.  A,  Prespermatic  group 
of  glands. 

In  order  to  determine  the  relation  of  the  ejaculatory  ducts  to  the 
urethra  and  the  prostatic  lobes,  I  have  made  transverse  and  longi- 
tudinal sections  in  the  specimens  both  of  normal  and  of  hypertrophied 
prostate. 

The  accompanying  illustrations  show  very  graphically  the  course 
of  the  ejaculatory  ducts  in  the  normal  state  (Figs.  4  and  5).  As  seen 
here,  if  we  trace  them  backward  from  their  urethral  orifices  we  find 
that  they  rapidly  approach  the  posterior  capsule  of  the  prostate;  that 
the  tissue  separating  them  from  the  urethra  gradually  increases,  and 
that  the  point  of  junction  of  the  seminal  vesicle  and  vas  is  reached 
considerably  in  front  of  the  junction  of  the  prostate  with  the  bladder. 
Stained  sections  of  the  posterior  portion  show  a  considerable  agglom- 
eration of  the  glandular  tissue  surrounded  by  encircling  muscular  and 
connective-tissue  fibers  which  separate  it  more  or  less  markedly  from 
the  glandular  tissue  of  the  adjoining  lateral  lobes.     This  mass  of 


12 


Eugli  H.  Young. 


glands  has  been  called  by  Albarran '  the  prespermatic  group,  and  this 
it  is  which  is  most  concerned  in  the  production  of  median  lobe  en- 


S ^ 


Fig.  5. — Cross  section  of  normal  prostate.  A,  At  a  point  just  in  fronr 
of  opening  of  ducts  and  utricle;  B,  at  opening  of  utricle  and  ducts;  C  and  1) 
5-10  mm.  back;  E,  at  entrance  into  bladder;  G,  at  the  junction  of  seminal 
vesicles  and  ampullae;  E,  the  seminal  vesicles  and  ampullae  separated. 

largements.     If  this  mass  of  glands  (Fig.  6,  A)  is  only  slightly  hyper- 
trophied  a  median  bar  may  be  produced,  which  may  be  continuous  with 


'Albarran  and  Motz:    Annales  d.  Mai.  d.  Organes  Genito-Ur.,  July,  1902. 


study  of  145  Cases  of  'Perineal  Prostatectomy. 


13 


the  lateral  enlargements  on  each  side,  the  whole  forming  a  collar 
around  the  prostatic  orifice.  If,  however,  this  group  takes  on  con- 
siderable hypertrophy  a  sessile  or  pedunculated  intravesical  median 
lobe,  sometimes  of  huge  dimensions,  results.  In  these  latter  varieties 
another  group  of  glands  which  lie  just  beneath  the  mucosa  where  the 
trigone  joins  the  urethra,  and  which  Albarran  has  called  the  sub- 
cervical  group,  may  take  part  in  the  hypertrophy.  All  these  median 
enlargements  grow  upward,  away  from  the  ejaculatory  ducts,  from 
which  they  are  separated  by  considerable  tissue,  including  their  en- 
capsulating fibers. 


Fig,  6. — Longitudinal  section  of  a  prostate,  with  great  hypertrophy  of 
the  median  and  lateral  lobes.  Urethra  very  wide  and  thin.  Note  low  in- 
sertion of  ducts. 


In  the  hypertrophied  prostate  the  position  of  the  ejaculatory  ducts 
and  vesicles  depends  considerably  on  the  character,  size,  and  disposition 
of  the  enlargements.  If  the  hypertrophy  is  great,  and  especially  if  a 
considerable  median  lobe  is  present,  the  vesical  neck  is  generally 
found  elevated  far  above  the  level  of  the  ducts  and  vesicles,  as  shown 
in  Fig.  6,  which  is  a  longitudinal  section  of  a  prostate  in  which  the 
lateral  and  median  lobes  are  all  three  greatly  hypertrophied.  The 
ducts  enter  so  low  down  on  the  posterior  surface  of  the  prostate  that 
the  median  lobe  is  not  in  relation  to  them  at  all,  and  is  separated  from 
the  vesicles  by  the  prostatic  capsule.  It  would,  therefore,  be  easy  to 
enucleate  this  lobe  without  injuring  the  ducts  at  all  if  properly  done. 
Note  here  also  the  great  width  of  the  urethra,  the  proximity  of  its 


14 


Hugh  H.  Young. 


floor,  and  the  sharp  bend  which  it  makes  in  front  of  the  middle  lobe. 
Cross-section  A  (Fig.  7)  is  taken  where  the  utricle  and  one  duct 
enter  the  urethra ;  B  is  taken  a  little  further  back  and  shows  the  ducts 


(^)    ^^) 


Fig.  7.— Six  cross  sections  of  the  same  prostate  at  different  levels,  as 
in  Fig.  .5.  The  ducts  rapidly  approach  the  posterior  capsule  and  in  D 
are  already  outside  of  it.  A  shows  the  beginning  of  the  median  lobe,  and  F 
just  before  the  entrance  of  the  urethra  into  the  bladder. 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  15 

midway  between  the  posterior  capsule  and  the  urethra.  Xote  the 
inverted  Y  urethra  produced  by  the  verumontanum  below  and  the 
pressure  of  the  lateral  lobes  against  each  other  in  front,  and  the  slit- 
like character  of  the  urethra.  In  G  the  ducts  lie  very  close  to  the 
capsule. 

Section  D,  which  has  been  taken  through  about  the  middle  of  the 
prostatic  mass,  shows  the  junction  of  the  vesicle  and  vas  just  outside 
the  prostatic  capsule.  ISTote  the  greater  distance  of  the  urethral  floor 
from  the  capsule.  This  is  shown  in  still  greater  amount  in  C,  and 
the  vesicles  and  ampuUge  are  here  seen  to  be  separated  from  the  median 
mass  by  the  prostatic  capsule.  In  F,  which  is  taken  about  5  mm.  in 
front  of  the  vesicle  orifice  of  the  prostate,  the  further  elevation  of 
the  median  lobe  is  sho"^Ti.  The  full  extent  of  the  median  lobe  is 
shown  in  the  median  section  (Fig.  6). 


Fig.  8. — Side  view  of  hypertrophied  prostate,  showing  low  entrance  of 
ducts  on  posterior  surface. 

Figure  8  is  a  side  view  of  another  specimen  in  which  the  vesicles 
and  vasa  join  the  prostate  low  down  on  the  posterior  surface. 

In  cases  of  little  or  no  median  lobe  enlargement  the  hypertrophied 
lateral  lobes  seem  also  to  carry  the  vesical  neck  upward  and  leave  the 
vasa  behind,  so  that  they  are  often  found  entering  the  capsule  well 
down  on  its  posterior  surface,  as  depicted  in  Fig.  8,  the  side  view  of 
a  specimen  of  considerable  hypertrophy  of  the  right  lateral  lobe.  The 
aponeurosis  of  Denonvilliers,  which  is  firmly  attached  to  the  posterior 
surface  of  the  seminal  vesicles  and  of  the  prostate  below  their  en- 
trance, and  which  binds  the  two  together  closely,  may  be  responsible 
for  the  upward  growth  of  the  hypertrophied  prostate  and  the  result- 
ant low  insertion  of  the  ducts  into  the  posterior  surface. 

The  results  of  this  study  of  the  course  of  the  ejaculatory  ducts  may 
be  thus  summarized : 


16 


Hugh  H.  Young. 


In  the  normal  prostate  the  ejaculatory  ducts  lie  for  the  most  part 
just  beneath  the  posterior  capsule,  considerably  below  the  level  of 
the  vesical  neck,  and  are  separated  from  it  by  the  prespermatic  group 
of  glands. 

In  the  hypertrophied  prostate  the  same  statements  are  true,  the 
only  difference  being  that  the  ducts  enter  relatively  lower  down,  and 
the  vesical  neck  is  separated  from  them  by  much  more  tissue,  especi- 
ally if  the  prespermatic  group  of  glands  have  taken  on  growth  with 


Fig.  9. — iThe  inverted  V  cutaneous  incision. 


the  resulting  median  lobe  enlargement,  in  which  case  the  vesical  orifice 
is  lifted  high  up  above  the  level  of  the  ducts.  The  prostatic  tissue  im- 
mediately adjacent  to  the  ducts  is  beneath  the  urethra  and  plays  no 
part  in  the  obstruction,  which  is  caused  entirely  by  the  lateral  and 
median  enlargements,  both  of  which  are  well  above  the  ejaculatory 
duets. 

The  measures  which  I  have  adopted  to  preserve  the  integrity  of  the 
ejaculatory  ducts  and  sexual  puissance  of  the  patient  I  will  take  up 
a  little  later. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  17 

TECHXIC  OP  THE  OPEEATION. 

Position  of  the  patient. — The  exaggerated  dorsal  lithotomy  position 
is  the  most  satisfactory.  The  perineal  board  of  the  Halsted  table  is 
admirably  suited  for  this  purpose.  The  perineum  should  be  so  ele- 
vated that  it  is  almost  parallel  with  the  floor.  Before  placing  the 
patient  on  the  table  a  No.  24F  sound,  to  be  used  as  a  guide  for  sub- 
sequent urethrotomy,  should  be  placed  in  the  urethra,  as  it  is  difl&cult 
to  introduce  it  after  the  thighs  have  been  flexed. 

Cutaneous  incision. — I  generally  use  an  inverted  Y-shaped  incision, 
as  shown  in  Fig.  9.  The  ap-^ix  is  taken  just  over  the  posterior  part  of 
the  bulb,  and  the  two  branches  are  each  5  cm.  long,  the  posterior  limits 


Fig.   10. — Exposure  of  bulb,  central  tendon  and  levatores  ani. 

being  about  midway  between  the  anus  and  ischial  tuberosities.  This 
incision  is  carried  through  the  skin  fat  and  superficial  fascia.  The 
handle  of  the  scalpel  is  then  used  on  each  side  of  the  central  tendon  to 
open  up  the  space  back  of  the  bulb  and  in  front  of  the  levator  ani 
muscles  as  shown  in  Fig.  10.  This  blunt  dissection  should  be  car- 
ried well  down  behind  the  triangular  ligament  on  each  side,  before 
sectioning  any  muscular  structures.  It  is  easily  accomplished  and  a 
good  exposure  simplifies  the  next  step  in  the  operation. 

Exposure  of  the  mernbranous  urethra. — After  exposure  of  the  cen- 
tral tendon  by  blunt  dissection,  the  bifid  retractor  (Figs.  11  and  12) 
is  inserted  as  shown  in  Fig.  13.  Traction  upon  this  instrument  gives 
an  excellent  exposure  of  the  narrow  band  of  central  muscle  and  greatly 
facilitates  its  division  close  to  the  bulb.  Great  care  should  be  taken 
not  to  puncture  the  bulb — an  accident  which  leads  to  inconvenient 
Vol.  XIV.— 2. 


18 


Hugh  H.  Young. 


hemorrhage.  After  the  central  tendon  has  been  completely  divided 
a  retractor  may  be  placed  beneath  the  bulb,  thus  affording  a  better  view 
of  the  recto-urethralis  muscle,  which  lies  beneath  the  two  branches  of 


Fig.  11. — Bifid  retractor. 


Fig.  12. — Bifid  retractor.     Side  view. 


the  levator  ani  and  covers  the  membranous  urethra  and  the  apex  of 
the  prostate  in  the  median  line.*  The  special  retractor  shown  in  Fig. 
16a  is  well  adapted  for  this  purpose.     The  concavity  in  the  middle 


*  The  recto-urethralis  is  a  short  muscle  with  rather  indefinite  margins, 
which,  as  its  name  indicates,  joins  the  rectum  with  the  urethra.  It  is 
apparently  responsible  for  the  acute  anterior  flexure  of  the  rectum  which 
lies  so  close  to  the  apex  of  the  prostate  and  membranous  urethra  and  which 
one  finds  in  rectal  examinations.  In  order  to  reach  the  membranous 
urethra  and  the  apex  of  the  prostate,  it  is  necessary  to  divide  this  muscle, 
as  shown  in  Fig.  13.  This  at  once  exposes  the  "  espace  decollable  retro- 
prostatique  "  which  has  been  so  well  described  by  Proust,  who  has  shown 
that  unless  this  muscle  is  divided  the  operator  is  apt  to  tear  into  the 
rectum,  which  is  drawn  forward  by  it.  Division  of  this  muscle  allows  the 
rectum  to  drop  back,  and  leads  at  once  into  the  space  surrounding  the 
posterior  surface  of  the  prostate. 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy. 


19 


allows  it  to  partly  encircle  the  urethra  and  catch  the  triangular  liga- 
ment. 

At  this  stage  it  is  generally  best  to  remove  the  "  bifid  retractor  " 
and  to  insert  a  narrow-bladed  retractor  about  two  inches  in  depth,  by 
which  the  rectum  can  be  pushed  back  and  the  muscular  fibers  sur- 
rounding the  membranous  urethra — the  recto-urethralis — put  upon 
tension.  They  are  then  divided  by  a  transverse  incision  close  up  to 
the  triangular  ligament  and  the  membranous  urethra  exposed  by  blunt 
dissection. 


Fig.  13. — Showing  bifid  retractor,  exposing  and  making  tension  on  the 
central  tendon. 


Uretlirotomy  and  insertion  of  tractor. — After  the  membranous 
urethra  has  been  exposed  by  division  of  the  recto-urethralis  muscle 
a  retractor  is  inserted  and  the  apex  of  the  prostate  brought  into  view, 
as  shown  in  Fig.  14.  The  membranous  urethra  is  then  opened  on  a 
sound  (which  was  inserted  in  the  urethra  before  the  patient 
was  put  in  the  lithotomy  position),  and  the  edges  of  the  urethral 
wound  caught  up  by  silk  sutures  or  preferably  by  Halsted  clamps.     A 


20 


Hugli  H.  Young. 


sound  of  moderate  size  is  then  passed  through  the  incision  into  the 
prostatic  urethra  and  bladder,  and  the  sphincters  dilated  by  a  to-and- 
fro  motion  of  this  instrument.  The  prostatic  tractor,  closed  (Fig.  2), 
is  then  passed  into  the  bladder,  the  edges  of  the  urethral  wound  being 
held  open  by  the  silk  sutures  to  facilitate  its  introduction.' 

As  soon  as  the  beak  is  free  in  the  vesical  cavity  the  thumb-screw 


Fig.  14. — Opening  of  urethra  on  sound,  preparatory  to  introduction  of 
tractor. 

which  fixes  the  blades  in  position  is  loosened,  the  blades  rotated  180 
degrees  by  means  of  the  external  blades,  and  then  fixed  by  tightening 
the  thumb-screw  (Fig.  3). 


^  Carelessness  in  this  part  of  the  operation  may  lead  to  considerable 
trouble.  If  the  membranous  urethra  is  not  carefully  exposed  and  thor- 
oughly opened,  difficulty  may  be  experienced  in  picking  up  the  edges 
of  the  mucosa  of  the  urethra  on  each  side.  If  the  edges  of  the  mucosa 
are  not  carefully  secured  with  clamps  and  held  apart,  they  may  be  inverted 
by  the  introduction  of  the  tractor  and  the  operation  delayed  until  they 
can  be  picked  up  again. 


study  of  145  Cases  of  Perineal  Prostatectomy. 


21 


The  instrument  is  now  ready  for  whatever  traction  may  be  neces- 
sary to  draw  the  prostate  well  down  into  the  perineal  wound,  as  shown 
in  Fig.  15.     Fig.  16  shows  the  position  of  the  blades  in  the  interior 


Fig.  15. — Tractor  introduced;  blades  separated,  traction  made,  exposing 
posterior  surface  of  prostate.  Incisions  in  capsule  on  each,  side  of  ejacu- 
latory  ducts. 


of  the  bladder,  each  blade  projecting  laterally  so  as  to  engage  the 
intravesical  surface  of  the  lateral  lobe. 


22 


Hugh  H.  Young. 


Exposure  of  prostate  and  incision  of  capsule. — Lateral  retractors 
are  so  placed  that  with  the  posterior  retractor  (Fig.  17)  drawing  the 
rectum  hack^^'ard,  and  the  prostatic  tractor  drawing  the  gland  out- 
ward, a  splendid  exposure  of  the  entire  posterior  surface  of  the  pros- 
tate is  obtained." 

These  retractors  should  be  especially  made  to  suit  the  diameters  of  the 
space,  as  shown  in  Figs.  17  and  18.  An  incision  is  then  made  on  each 
side  of  the  median  line  for  almost  the  entire  length  of  the  posterior 
surface  of  the  prostate  and  about  1.5  cm.  deep.     The  two  lines  are 


Fig.  16. — Showing  position  of  blades  in  interior  of  bladder  in  case  of 
median  and  bilateral  hypertrophy. 

divergent,  as  shown  in  Fig.  15,  being  about  1.8  cm.  behind  and  1.5 
cm.  apart  in  front.     The  bridge  of  tissue  which  lies  between  them 


^  Even  after  the  insertion  of  the  tractor  care  must  be  taken  in  the 
further  separation  of  the  prostate  and  rectum,  which  is  sometimes  closely 
adherent  along  the  entire  posterior  surface  of  the  prostate.  After  the 
apex  of  the  prostate  has  been  thoroughly  exposed  so  that  the  white  capsule 
is  plainly  visible,  the  rest  of  the  posterior  surface  of  the  prostate  is  freed 
by  gradually  pushing  back  the  rectum  with  the  handle  of  a  scalpel,  and 
dividing  any  muscular  bands  or  fibrous  adhesions  which  hinder  the  process 
of  separation,  but  being  careful  to  work  against  the  prostate  and  not  to- 
wards the  rectum.  The  finger  is  particularly  dangerous  and  nearly  all  the 
cases  of  rectal  tear  to  which  my  attention  has  been  called,  have  been  pro- 
duced by  the  finger  in  attempting  to  rapidly  push  back  the  rectum. 


study  of  lJf5  Cases  of  ■Perineal  Prostatectomy. 


23 


contains  the  ejaculatory  ducts,  and  its  preservation  is  of  importance, 
if  the  integrity  of  these  non-obstructive  structures  is  to  be  left  unin- 
jured. It  is  for  this  purpose  that  I  make  the  initial  capsular  incision 
1.5  cm.  deep  on  each  side,  and  these  define  at  once,  and  correctly,  the 


Fig.  16a. — Anterior  retractor  for  drawing  forward  bulb  and  transverse 
perineal  muscles  to  expose  the  membranous  urethra. 


Fig.  17. — Posterior  retractor 


Fig.  18. — One  of  the  lateral  retractors. 


Fig.  19. — Blunt  dissector  or  enucleator. 


width  of  the  "ejaculatory  bridge,"  and  prevent  its  being  torn,  as 
might  happen  if  we  depended  on  blunt  dissection.  Another  advan- 
tage is  that  these  incisions  bring  us  at  once  to  the  side  of  the  urethra 
where  the  internal  enucleation  (urethra  from  inner  surface  of  lobe) 
can  be  easily  accomplished  later  on. 


34 


Hugh  H.  Young. 


Enucleation  of  lateral  lubes. — We  are  now  ready  to  begin  the  ex- 
ternal enucleation,  the  separation  of  the  capsule  from  the  lateral  lobes, 
which  is  best  done  with  the  blunt  dissector,  as  shown  in  Figs,  19  and 
20.  Capsules  are  of  varying  thiclmess,  and  contain  several  layers  of 
cleavage.  It  is  important  to  start  the  separation  in  the  right  layer, 
not  too  deep  as  you  may  be  led  into  the  substance  of  the  lobe,  and  not 
so  superficially  as  to  be  outside  of  the  most  of  the  capsule.     After  the 


'I 

u^9^^ 

^^^r^ 

^ 

* 

*l 

#1^^ 

^ 

^ 

1 

■ 

/ 

^S^fe-"*"^"™ 

f 

/. 

Fig.  20. — External  enucleation  begun. 


stripping  up  process  has  been  started  correctly  it  is  easily  continued  by 
blunt  dissectors  until  first  the  lateral  and  then  the  anterior  surface  of 
the  lateral  lobes  have  been  freed  from  the  capsule. 

The  internal  enucleation  should  be  taken  up  after  the  external,  as 
it  is  a  much  more  delicate  procedure  and  often  requires  considerable 
care  to  prevent  tearing  into  the  urethra.  As  remarked  above,  the 
primary  incision  is  made  with  the  scalpel  until  pa,st  the  level  of  the 
urethra  after  which  the  blunt  dissector  is  used.  During  this  procedure 
the  shaft  of  the  prostatic  tractor  is  grasped  firmly  in  the  operator's 


study  of  H5  Cases  of  Perineal  Prostatectomy. 


25 


left  hand  (Fig.  15)  and  serves  not  only  to  draw  the  prostate  so  well 
down  into  the  cutaneous  wound  that  every  procedure  is  done  in  plain 
view,  but  to  steady  the  prostate  and  to  mark  out  the  course  of  the 
urethra  so  that  it  can  be  avoided.  At  the  apex  of  each  lateral  lobe  firm 
adhesions  to  the  capsule,  usually  requiring  divisions  with  scissors,  are 
nearly  always  present. 

When  the  enucleation  of  a  lateral  lobe  has  progressed  fairly  well  on 
each  side,  it  is  advantageous  to  have  traction  made  on  the  lobe  itself 
in  order  to  facilitate  the  separation  of  the  deeper  portion,  I  tried 
various   instruments — vulsellum   forceps,   pedicle   forceps,   and  hook 


Fig.  21. — Lobe  forceps. 


retractors — for  this  purpose,  but  I  found  that  all  toothed  instru- 
ments quickly  tore  through  the  friable  tissue  whenever  traction  suffi- 
cient to  be  of  any  assistance  in  drawing  out  the  lobe  was  used.  It, 
therefore,  seemed  advisable  to  have  fenestrated  forceps  which  could 
grasp  the  entire  lobe,  and  present  such  broad  surfaces  to  it  that  no 
cutting  or  tearing  of  the  capsule  would  be  done.  I  accordingly  de- 
signed the  instruments  shown  in  Fig.  21.  The  two  blades  grasp  the 
prostate  with  broad  surfaces,  so  shaped  as  to  hold,  but  not  to  cut  the 
lobe  when  pressure  is  applied  (Fig.  22). 

The  lobes  usually  come  out  each  in  one  piece,  and  it  is  possible  to 
apply  considerable  traction  without  tearing  them,  thus  greatly  facili- 
tating the   deeper   enucleation.     Much   of   the   enucleation   is   done 


26 


Hugh  H.  Young. 


Fig.  22. — Enucleation  of  lobes.     Forceps  in  position. 


Fig.  22a. — Two  lobes  removed  by  perineal  prostatectomy.     Actual  size. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy. 


27 


with  the  blunt  dissector,  but  when  the  intravesical  portion  of  the 
lateral  lobe  is  reached  I  generally  use  the  finger  so  as  to  avoid  tearing 
through  the  thin  mucous  membrane  covering  it. 

The  intravesical  blade  of  the  prostatic  tractor,  which  can  be  dis- 
tinctly palpated  through  the  mucous  membrane  by  the  enucleating 
finger,  serves  to  direct  the  separation  of  the  deeper  portion,  and  warns 
against  tearing  into  the  bladder.  It  also  shows  when  some  of  the 
lobe  has  been  left  behind.  The  condition  present  after  the  enucleation 
of  the  two  lateral  lobes,  as  described  above,  are  shown  in  Pig.  23. 


Fig.  23. 


Fig.  24. 


■     Fig.    23. — Schematic    cross    section    after    enucleation    of    lateral    lobes, 
showing  ducts  and  median  bridge  of  tissue.     Instrument  in  urethra. 
Fig.  24. — The  blade  rotated  so  as  to  engage  middle  lobe. 


As  shown  in  this  schematic  cross-section,  the  urethra,  which  contains 
the  tractor,  is  left  intact.  Beneath  is  the  bridge  of  tissue  surrounding 
the  ejaculatory  ducts.     The  empty  capsule  is  shown  on  each  side. 

Enucleation  of  the  middle  late. — After  the  lateral  lobes  have  been 
shelled  out,  attention  should  be  directed  to  the  median  portion  of  the 
prostate.  If  the  previous  cystoscopic  examination  has  demonstrated  a 
thin  transverse  bar,  it  will  sometimes  be  found  that  removal  of  the 
lateral  lobes  has  allowed  it  to  collapse,  showing  that  it  was  really  an 
artefact,  a  fold  of  mucous  membrane  hooked  up  by  the  lateral  out- 
growths, and  not  containing  any  hypertrophied  tissue. 


Fig.  25. — Shovring  teclinique  of   delivery  of  middle  lobe  imo   cavity  of 
left  lateral  lobe. 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  29 

On  the  other  hand,  there  is  most  often  a  more  or  less  extensive 
hypertrophy  of  the  prespermatic  group  of  glands,  and  the  mass  can 
be  easily  seen,  or  felt  by  the  finger  in  one  of  the  intracapsular  cavities 
(Fig,  25).  Further  examination  will  generally  reveal  a  fair  amount 
of  tissue  between  the  median  lobe  and  the  region  of  the  ejaculatory 
duets,  which,  as  I  have  previously  pointed  out,  lie  well  forward  on 
the  posterior  surface,  and  close  to  the  capsule.  The  median  enlarge- 
ment is  generally  more  or  less  definitely  attached  to  one  or  both  of 
the  lateral  lobes  so  that  there  is  no  difficulty  in  shelling  it  out  through 


Fig.  25a. — Photograph  of  a  pedunculated  median  lobe  which  was  re- 
moved through  the  cavity  left  by  left  lateral  lobe  without  tearing  urethral 
or  vesical  mucosa.    The  three  lobes  are  shown  in  exact  size. 

one  of  the  lateral  cavities — without  disturbing  the  integrity  of  the 
ejaculatory  ducts  and  prostatic  tissue  immediately  surrounding  them. 
The  prostatic  tractor  may  be  used  with  great  advantage  in  removing 
a  median  lobe,  and  the  technique  which  I  generally  employ  to  draw 
it  down  into  one  of  the  lateral  cavities  where  it  can  be  enucleated,  is 
as  follows:  Push  the  tractor  backward  until  free  in  the  bladder 
cavity,  depress  the  handle  of  the  instrument  so  that  the  shaft  can  lie 
on  the  top  of  the  middle  lobe,  and  then  rotate  the  instrument  90 
degrees,  so  that  one  of  the  blades  projects  downward  behind  it.     Out- 


30 


Hugh  H.  Young. 


ward  traction  should  then  engage  the  lobe,  as  shown  in  Fig.  24,  and 
drawn  down  where  it  can  be  seen  by  the  operator.  To  get  it  into  one 
lateral  intracapsular  cavity  (say  to  the  left)  two  manoeuvres  are  of  help  : 
Pushing  against  it  with  the  index  finger  of  the  left  hand,  which  has 
been  inserted  in  the  right  intracapsular  cavity,  as  seen  in  Fig.  25,  and 
rotation  of  the  blade  engaging  the  middle  lobe  in  the  same  direction, 
making  traction  on  it  all  the  while.     Fig.  25a  shows  a  pedunculated 


Fig.  26. 


Fig.  28. 


Fig.  26. — Photograph  of  prostate  in  which  the  left  and  median  lobes 
were  enucleated  in  one  piece.     Exact  size. 

Fig.  27. — Longitudinal  section  after  enucleation  of  median  lobe  through 
a  lateral  cavity. 

Fig.  28. — Cross  section  at  level  of  cavity  left  by  median  lobe. 


median  lobe  that  was  removed  in  this  way  without  injury  of  the 
mucosa  covering  it  (Case  No.  12). 

After  the  median  lobe  has  presented  in  the  left  intracapsular  cavity, 
the  operator  turns  the  tractor  over  to  an  assistant  who  continues  the 
traction,  while  he  grasps  the  lobe  with  the  forceps  described  above 
and  then  rapidly  enucleates  it. 


study  of  lJj.5  Cases  of  ■Perineal  Prostatectomy. 


'61 


In  many  instances  I  have  found  the  median  mass  to  be  directly  con- 
tinuous with  the  left  lateral  lobe,  and  when  the  deeper  portion  of  that 
lobe  was  being  freed,  that  the  median  lobe  was  disposed  to  come  with 
it.  I  have  then  rotated  my  tractor  so  as  to  engage  the  median,  and 
have  readily  drawn  it  down  and  enucleated  the  two  in  one  piece,  as 
shown  in  Fig.  26.  In  another  case  a  collar-like  growth,  consisting  of 
a  median  bar  and  two  lateral  masses,  was  easily  enucleated  in  en- 
tirety through  the  left  intracapsular  cavity  without  tearing  the  ducts 
beneath  or  the  mucous  membrane  of  the  urethra  or  bladder. 


Fig.  29. — Blade  engaging  anterior  lobe. 


I  have  now  had  many  cases  with  very  great  intravesical  median 
lobes,  and  have  experienced  little  diflQculty  in  drawing  these  down 
with  the  tractor  into  a  lateral  cavit}^  where  enucleation  was  easily 
accomplished.  A  large  median  lobe  is  no  longer  considered  more 
suitable  for  suprapubic  prostatectomy. 

The  condition  present  after  the  enucleation  of  a  median  lobe,  as 
described  above,  is  shown  schematically  in  Figs.  37  and  .28.  Fig.  2T  is 
a  longitudinal  section  showing  the  cavity  left  by  removal  of  this  lobe, 
the  ejaculatory  ducts  being  below  and  in  front  and  quite  distant  from 
it.  In  Fig.  28  the  median  cavity  is  seen  to  communicate  with  the 
lateral  cavities  on  each  side,  beneath  the  intact  urethra.  The  seminal 
ducts  are  separated  from  the  capsule  by  the  posterior  capsule. 

Tlie  removal  of  an  anterior  lobe. — The  presence  of  a  definite  isolated 


32 


Hugh  H.  Young. 


anterior  lobe  is  of  rare  occurrence.  We  occasionally  see  with  the 
cystoscope  small  anterior  outgrowths,  but  they  are  generally  continuous 
with  a  lateral  lobe. 

One  of  my  cases  was  of  this  character,  and,  although  it  looked 
through  the  cystoscope  like  a  large  rounded  mass,  I  found  that  it  came 
away  easily  with  the  lateral  lobe.  I  employed  a  procedure  the  reverse 
of  that  which  I  have  just  described  for  posterior  middle  lobes,  the 


Fig.  30. — The  use  of  index  finger  to  deliver  a  small  median  lobe  into 
lateral  cavity. 


anterior  lobe  being  engaged  by  a  blade  which  was  directed  upward, 
as  shown  in  Fig.  29.  The  entire  mass  (left  lateral  and  anterior  lobe) 
was  very  large,  measuring  7x6x5  cm. 

In  another  case  a  large  detached  anterior  lobe  was  easily  drawn 
down  and  enucleated  through  the  right  lateral  cavity. 

The  ability  to  make  traction  on  any  desired  portion  of  the  prostate 
is  of  the  very  greatest  value  and  assistance,  especially  in  enucleating 
these  unusual  outgrowths  of  the  hypertrophied  gland. 


study  of  H5  Cases  of  ■Perineal  Prostatectomy.  33 

THE  USE  OF  THE  INDEX  FINGER  AS  A  RETRACTOR. 

There  are  some  cases,  however,  in  which  the  median  enlargement  is 
in  the  shape  of  a  small  bar  or  lobe,  so  adherent  that  it  is  difficult  to 
engage  it  with  the  blade  of  the  tractor,  as  described  in  my  first  paper, 
and  for  these  I  have  of  late  employed  the  index  finger  of  the  left  hand 
in  place  of  the  tractor  in  the  urethra,  to  push  the  lobe  into  the  lateral 
cavity.  After  the  tractor  has  been  withdrawn  the  left  index  finger  is 
inserted  gently  through  the  prostatic  urethra,  until  the  tip  is  free 
in  the  bladder.  Examination  will  then  reveal  the  median  bar  or 
lobe  which  remains,  and  it  is  an  easy  matter,  by  crooking  the  finger 
over  it,  to  carry  it  into  the  left  lateral  cavity  where  it  can  be  enu- 
cleated (Fig.  30),  If  an  adherent  bar  is  encountered  a  sharp 
periosteal  elevator  is  a  good  instrument  with  which  to  peel  it  out. 
Occasionally  it  may  be  necessary  to  use  scissors  for  this  purpose, 
and  to  get  hold  of  the  mass  to  be  removed  as  it  begins  to  be  separated, 
a  long  forceps  may  be  required. 

In  several  of  my  cases  it  has  been  impossible  to  engage  with  the  blade 
of  the  tractor  a  very  small  rounded  or  pedunculated  median  lobe, 
but  I  have  been  able,  by  using  the  finger  instead  of  the  tractor,  to 
successfully  remove  it  without  injuring  the  urethra  or  the  ejaculatory 
ducts.  The  technique  described  above  is  entirely  different  from  that 
of  Albarran,  who  draws  the  median  lobe  into  the  widely  opened  urethra 
with  the  finger.' 

A  very  pedunculated  middle  lobe  may  evade  both  the  finger  and  the 
tractor,  and  in  such  instances  it  may  be  best  to  insert  a  curved  clamp 
and  draw  the  middle  lobe  down  the  dilated  urethra  where  it  may  be 
enucleated  or  divided  with  scissors.  This  is  the  technique  employed 
by  Albarran. 

A  SUBURETHRAL  METHOD  OF  REMOVING  A  MEDIAN  BAR  OR  LOBE. 

In  case  the  patient  has  already  lost  his  sexual  powers  the  reason  for 
preserving  the  ejaculatory  ducts  does  not  hold,  and  in  such  cases, 
when  the  median  bar  or  lobe  is  too  small  or  too  adherent  to  be  deliv- 

''  Albarran's  technique  may  sometimes  be  of  value  in  cases  of  pedun- 
culated middle  lobes  of  small  size.  I  have  used  it  several  times,  but  usually- 
considerable  laceration  of  the  urethra  has  been  produced  and  there  is 
more  hemorrhage  than  with  my  technique  in  which  the  mucous  membrane 
is  not  removed. 

Vol.  XIV.— 3. 


34 


Hugh  H.  Young. 


ered  into  a  lateral  cavity  with  the  tractor,  I  have  removed  the  mass 
subiirethrally,  after  transverse  division  of  the  ejacnlatory  bridge,  as 
shown  in  Fiff.  31. 


Fig.  31. — Showing  suburethral  method  of  enucleating  median  bar. 


Fig.    32. — Schematic   longitudinal   section   of   the   urethra,    showing   the 
median  enlargement  enucleated  beneath  the  urethra. 


After  stripping  back  the  capsule  (Fig.  32)  it  is  an  easy  matter  to 
shell  out  or  to  excise  the  median  bar  or  lobe  without  opening  the 
urethral  or  vesical  mucous  membrane  coverinsr  it. 


study  of  145  Cases  of  'Perineal  Prostatectomy. 


35 


Fig.  33  shows  a  small  median  bar  which  was  removed  in  this  way 
after  the  enucleation  of  two  large  lateral  lobes.  The  patient  had  been 
castrated  and  there  was  therefore  no  object  to  be  gained  by  preserving 
the  ejacnlatory  ducts.     (Case  25.) 

In  some  cases  in  which  it  is  desirable  to  preserve  the  ejacnlatory 
ducts,  a  fibrous  median  bar  may  be  removed  through  one  of  the 
lateral  cavities  of  the  prostate,  after  division  of  one  of  the  lateral  walls 
of  the  urethra,  as  shown  in  Fig.  34.     In  this  way  the  "  ejaculatory 


Fig.  33. — Photograph,  natural  size. 


bridge "  is  preserved.     This  method  has  been  employed  in   several 
cases. 

In  the  great  majority  of  cases  the  median  mass  can  be  enucleated 
through  the  lateral  cavity — the  larger  the  lobe  the  easier  it  is. 


TEEATMEXT   OF   VESICAL    CALCULUS   AS   A   COilPLICATIOX    OF   EXLARGED 

PROSTATE. 

When  calculus  is  present,  either  litholapaxy,  before  or  during  the 
prostatectomy  operation,  or  suprapubic  or  perineal  lithotomy  may  be 
performed.  Without  going  into  arguments  for  or  against  either  of 
these  procedures,  it  is  evident  that  if  a  perineal  prostatectomy  is  to 


!6 


Hugh  E.  Young. 


be  performed  the  ideal  procedure  is  to  remove  the  calculus  at  the 
same  sitting,  without  crushing  it,  for  litholapasy  is  in  these  cases  a 
tedious  procedure.  If,  however,  the  removal  of  the  calculus  intact 
will  seriouslj^  injure  the  urethra,  the  ejaculatory  ducts  or  the  neck 
of  the  bladder,  such  a  method  is  contraindicated.  To  drag  a  calculus 
by  main   force  out  through   the  urethra,   as   left  by   the   technique 


Fig.  34. — Division  of  lateral  wall  of  urethra  to  allow  extraction  of  large 
calculus  through  left  lateral  cavity. 


which  I  follow,  would  be  at  once  dangerous  and  destructive,  except 
when  it  is  small. 

I  have  therefore  endeavored  to  devise  a  method  which  would  be  free 
from  the  dangers  mentioned  above,  and  which  would  also  provide  for 
the  removal  of  large  stones.  The  technique  which  I  have  found  most 
satisfactory  is  graphically  shown  in  the  accompanying  drawing 
(Fig.  34). 


study  of  IJfO  Cases  of  ■Perineal  Prostatectomy. 


37 


x\s  seen  here,  tlie  urethra  is  split  with  scissors  along  its  left  lateral 
wall,  from  the  urethrotomy  wound  in  the  membranous  urethra  up  to 
its  vesical  orifice.  By  this  procedure,  the  urethra  becomes  a  common 
cavity  with  that  left  by  the  enucleation  of  the  left  lateral  lobe,  and 
abundant  room  is  furnished  for  the  extraction  of  calculi.  If  the 
cystoscope  has  shown  the  calculus  to  be  only  moderately  large  it  is 
usually  only  necessary  to  dilate  the  vesical  orifice  with  a  uterine  dila- 
tor in  order  to  extract  it  with  forceps.  If  the  calculus  is  too  large 
to  be  thus  withdrawn,  the  orifice  is  enlarged  by  a  cut  through  the 
vesical  mucous  membrane  covering  the  left  lateral  cavity  of  the  pros- 
tate, while  the  stone  is  held  firmly  against  it  by  forceps. 


Fig.   35. — Exact  size   of  calculus   removed  through   perineal   incision. 


I  have  followed  the  technique  described  above  in  24  cases  of  calculus 
which  are  described  in  full  in  another  part  of  this  paper.  Fig.  35 
shows  the  calculus  which  was  removed  by  this  method  in  one  case. 

The  ejaculatory  bridge  containing  the  ducts  is  not  injured,  no  ureth- 
ral nor  vesical  mucous  membrane  is  removed,  and  the  perineal  wound 
heals  just  as  rapidly  as  after  the  simple  prostatectomy;  in  one  case, 
perineal  leakage  ceased  after  the  ninth  day.  I  have  not  found  it  neces- 
sary to  close  the  divided  urethra  with  sutures,  but  have  simply  provided 
the  double  urethral  catheter  drainage  through  the  urethrotomy  wound 
and  the  gauze  packing  for  the  lateral  cavities  as  usual.  The  great 
advantage  of  perineal  over  suprapubic  lithotoni}^  is  that  the  patient 
can  be  propped  up  in  bed  at  once,  and  moved  into  a  wheel-chair  on  the 


38 


Hugh  II.  Young. 


third  or  fourth  day.  The  secret  of  success  in  these  cases,  is  to  flush 
the  kidneys  and  to  get  the  patients  out  of  bed  quickly,  and  this  cannot 
be  done  after  the  suprapubic  operation  with  the  same  impunity  and 
rapidly  as  in  the  perineal  cases.  In  some  cases  sectio  alta  may  be 
necessary,  though  an  attempt  to  crush  the  stone  through  the  perineal 
wound  may  be  a  decided  one.  A  very  careful  search  should  be  made 
for  additional  calculi.  If  much  blood  has  been  collected  in  the  blad- 
der it  is  often  advisable  to  evacuate  it  and  wash  out  the  bladder 
thoroughly  before  continuing  the  search.  "  Eecurrent  calculi "  after 
prostatectomy  are  usually  calculi  or  fragments  of  calculi  left  behind  at 
operation. 


Fig.  36.^ — Showing  how  the  tractor  may  slip  beneath  prominent  lateral 
lobes. 


Searching  for  undetected  intravesical  lohes. — The  median  and  the 
two  lateral  lobes  should  generally  be  completely  removed  each  in  one 
piece.  If  the  cystoscope  has  shown  any  peculiar  intravesical  out- 
growth, an  effort  should  be  made  to  remove  it  with  the  lobe  to  which 
it  is  attached  by  engaging  it  with  the  tractor.  In  order  to  secure 
it,  several  successive  attempts  may  be  necessary.  By  palpating  the 
entire  prostatic  margin  with  a  finger  in  a  lateral  cavity  against  the 
blade  of  the  tractor  a  lobule  which  has  been  left  behind  can  usually 
be  discovered. 

When  there  is  no  median  bar  or  lobe  to  hold  up  the  intravesical  por- 
tion of  the  prostatic  tractor,  the  blades  may  slip  beneath  prominent 
intravesical  lateral  outgrowths,  as  shown  in  Pig.  36.  This  happened 
in  one  of  my  early  cases  and  is  the  cause  of  an  imperfect  result.     Eo- 


study  of  145  Cases  of  'Perineal  Prostatectomy. 


39 


tation  of  the  tractor  and  palpation  with  the  finger,  as  described  above, 
should  prevent  such  an  oversight.  In  rare  instances  it  may  be  neces- 
sary to  use  the  index  finger  in  the  urethra  in  place  of  the  tractor, 
particularly  in  small  pedunculated  middle  lobe  cases,  as  described 
above.  Whenever  one  fails  to  find  what  has  been  shown  by  the  cysto- 
scope  the  digital  exploration  should  be  employed.  The  only  objection 
to  it  is  that  the  urethra  is  usually  split  open  by  the  procedure. 

Drainage. — Before  withdrawing  the  tractor  a  careful  examination 
should  be  made  bv  inserting  the  fino-er  into  both  of  the  lateral  cavities 


Fig.  37. — Scheme  of  continuous  irrigation  apparatus. 


and  palpating  the  blades  through  the  vesical  mucosa,  in  order  to 
determine  that  no  important  glandular  mass  has  been  left  behind. 
The  tractor  is  then  removed  by  first  rotating  the  blades  until  they 
come  together  and  then  withdrawing  the  instrument.  Abundant  ves- 
ical drainage  should  be  provided,  as  a  small  tube  may  easily  become 
plugged  by  blood-clots  and  give  great  annoyance  afterwards. 

I  now  use  two  catheters  of  fairly  good  size.  These  are  fastened 
together  by  ligatures  and  are  prepared  before  the  operation,  so  that 
as  soon  as  the  tractor  is  withdrawn  they  can  be  inserted  through  the 
perineal  wound  into  the  urethra  and  bladder.  In  order  to  facilitate 
their  introduction  it  is  best  to  cut  obliquely  across  the  end  of  each 


40 


Rugh  H.  Young. 


catheter  and  then  fasten  the  cut  surfaces  together  with  a  single  suture, 
thus  making  a  common  point  for  the  two  catheters.  If  this  is  not 
done  one  of  the  catheter  ends  may  catch  in  a  fold  of  mucous  membrane. 
One  catheter  is  immediately  connected  with  a  tank  of  normal  salt 
solution,  and  the  bladder  thoroughly  washed  clean  of  blood. 

After  the  tubes  have  been  properly  adjusted,  they  are  tied  by  a 


Fig. 
catgut. 


58.— Approximation  of  levator  ani  muscles  with  single  suture  of 


heavy  silk  suture  to  the  skin  at  the  upper  angle  of  the  wound.  The 
lateral  prostatic  cavities  are  then  firmly  packed  each  with  a  small 
strip  of  gauze,  but  care  is  taken  that  the  packing  is  confined  to  the 
lateral  cavities  of  the  prostate  and  especially  that  none  may  be 
allowed  to  press  against  the  rectum.  The  tube  and  gauze  drainage 
as  thus  provided  is  shown  in  Fig.  37. 

Approximation  of  the  levator  ani  muscles. — Before  closing  the  cu- 


study  of  1J/-5  Cases  of  'Perineal  Prostatectomy.  41 

taneous  woiind  one  should  always  examine  the  rectum.  With  a  gloved 
finger  inserted  through  the  anus  and  another  in  the  wound  the  rectal 
wall  should  be  carefully  examined  for  lacerations  or  weaknesses. 
During  this  procedure  it  is  well  to  hold  the  gauze  packing  and  tubes 
out  of  the  way  by  means  of  anterior  retraction  (Fig.  38). 

The  rectal  wall  above  the  anal  sphincter  is  usually  found  quite 
thin  even  in  cases  where  no  injury  has  been  done  to  it,  and  in  cases  where 
it  has  been  very  adherent  to  the  prostate  the  musculosa  may  be  some- 
what torn  and  should  be  drawn  together  with  a  suture  or  two  of  fine 
catgut.  If  a  definite  tear  into  the  rectal  cavity  should  be  found  (and 
this  occurred  four  times  with  me,  two  being  in  cases  with  large  opera- 
tive cicatrices  between  rectum  and  prostate)  careful  closure  should 
be  made  first  with  a  layer  of  interrupted  very  fine  silk  sutures  for  the 
submucosa,  then  one  for  the  musculosa,  and  finally  a  reinforcing  layer 
of  catgut  sutures.  Xo  trouble  should  be  experienced  in  effecting  a 
solid  closure  if  the  proper  needles  (very  fine  curved  patent-e3'e 
needles)  are  at  hand. 

After  satisfying  yourself  that  the  rectum  is  uninjured  the  levator 
ani  muscles  should  be  drawn  together  to  their  normal  position  in  front 
of  the  rectum.  This  can  be  accomplished  with  a  single  suture  of  heav}' 
catgut,  as  shown  in  Fig.  38.  It  is  remarkable  what  a  difference  this 
one  suture  will  make.  Before  its  insertion  the  levators  will  be  found 
widely  separated  (by  the  traction  which  has  been  made  against  them) 
and  the  thin  rectal  wall  will  be  found  bulging  between  them,  as  shown 
in  Fig.  38.  It  is  then  easy  to  understand  how  rectal  fistuls  occur,  for 
if  great  force  were  put  on  the  thin  unsupported  rectum  (as  at  stool) 
it  might  easily  give  way,  and  if  a  gauze  pack  were  allowed  to  press 
against  it,  necrosis  might  quickly  result. 

When  the  levator  sutTire  is  placed,  the  picture  changes  immediately, 
the  rectum  disappears  behind  the  firm  buttress  of  reapproximated 
levators  and  the  danger  of  rectal  breakdown  vanishes. 

Partial  closure  of  the  wound. — If  the  median  perineal  incision  has 
been  used,  the  posterior  portion  is  closed  by  buried  catgut  for  the 
muscle,  and  silk  or  catgut  interrupted  for  the  skin.  While  no  im- 
portant muscles  have  been  divided  (only  the  central  tendon  and  the 
recto-urethralis  muscle),  it  is  nevertheless  advisable  to  draw  together 
the  structures  which  have  been  so  widely  separated  by  retraction. 

If  the  inverted  V-incision  has  been  employed  the  two  branches  of 
Vol.  XIV.— 4. 


43  Hugh  H.  Young. 

the  incision  are  partly  closed,  as  shown  in  Fig.  39,  leaving  a  small 
area  in  front  of  the  gauze  and  tube  drains. 

Using  this  method  of  closure  thgre  is  no  more  distortion  of  the 
perineum  after  this  incision  than  after  the  median,  and  there  should 
not  be,  as  there  is  no  more  destruction  of  muscular  continuity  in  one 
than  in  the  other;  in  fact,  they  only  differ  in  the  cutaneous  incision. 

After-treatment. — The  patient  is  generally  returned  to  his  room 
accompanied  by  an  assistant  who  sees  that  the  irrigation  is  going 
well,  and  arranges  to  have  it  continued  after  he  has  been  placed  in 
bed.  The  apparatus  used  is  indicated  in  Fig.  37,  but  a  much 
larger  tank  is  employed.  We  now  use  a  two-gallon  porcelain  tank 
with  an  outlet  at  the  side.     The  flow  is  regulated  by  a  clamp  on  the 


Fig.  39. — Final  closure. 

inlet  tube.  The  outlet  tube  drains  into  a  jar  by  the  side  of  the  bed. 
If  the  end  is  kept  immersed  in  water,  air  cannot  get  up  the  tube, 
and  siphonage  is  obtained,  thus  keeping  the  bladder  empty  and  pre- 
venting leakage  around  the  perineal  tubes.  The  task  of  keeping  the 
reservoir  supplied  with  salt  solution  is  not  a  difficult  one,  the  nurse 
having  to  add  a  quart  about  every  half  hour.  It  is  not  necessary  to 
maintain  an  even  temperature — 110°  to  120°  F.  in  the  tank  is  about 
right — and  the  temperature  is  maintained  between  these  fairly  well 
by  the  half-hourly  addition  of  the  hot  salt  solution. 

A  submammary  infusion  of  1000  cc.  salt  solution  is  given  either  on 
the  operating  table  or  after  the  return  to  bed.  This  is  considered  so 
valuable,  both  as  a  preventative  to  shock  and  anuria,  and  as  a  cure 
for  post-operative  thirst,  that  it  is  never  omitted. 

The  gauze  drains  are  removed  on  the  day  after  the  operation  and  no 
more  packing  put  in.  The  tubes  are  pulled  out  a  few  hours  later, 
and  on  the  next  day  the  patient  is  usually  placed  in  a  wheel-chair, 
and  carried  out-doors.     ISTo  sounds  are  passed  and  stricture  never 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  43 

results.  Urotropin  is  administered  early,  and  water  is  given  in 
abundance  (by  infusion  every  two  or  three  days  if  advisable). 

Within  a  few  days  the  patient  is  generally  walking  about  the  hos- 
pital. IvTothing  is  done  to  the  wound  except  to  keep  it  clean,  and  to 
occasionally  cauterize  exuberant  granulations. 

I  may  say  that  the  instrument  which  I  have  called  "  prostatic 
tractor "  has  transformed,  for  me,  the  operation  of  prostatectomy. 
Where  before  (with  me — perhaps  not  with  others)  an  operation  was 
done  somewhat  haphazard,  depending  largely  on  the  sense  of  touch, 
and  in  the  dark;  now  the  entire  operation  is  performed  in  a  shallow 
wound,  accurately  under  visual  control,  proper  regard  being  paid  to  the 
urethra  and  to  the  ejaculatory  ducts. 

III.  An  Analysis  of  145  Cases  of  Perineal  Prostatectomy  for 
Hypertrophy  of  the  Prostate  in  which  the  Operation 
Described  Above  has  been  Employed. 

a.  the  onset  of  the  disease.     etiology. 

The  ages  of  the  patients  were  as  follows : 

35  to  39  1 

40  "  44  0 

45  "  49  3 

50  "  54  9 

55  "  59  20 

60  "  64 29 

65  "  69  38 

70  "  74  24 

75  "  79  , 16 

80  "  84  4 

85  "  90 1 

Total  145 

A  glance  at  this  table  shows  that  prostatic  enlargement  and  obstruc- 
tion occur  most  frequently  in  the  five  years  between  the  ages  of  65 
and  69  inclusive,  there  being  37,  or  26%  of  the  eases  during  that 
period  of  life.  The  decennium  60  to  69  contains  &%  cases,  or  46%. 
The  15  years  between  60  and  74  contains  90  cases,  or  62%,  and  the 
25  years  between  55  and  79  contains  126  cases,  87%.  There  are  only 
13  cases  under  55  years  of  age  and  five  cases  over  80  years  of  age. 

The  cases  under  55  years  of  age  were  briefly  as  follows,  between 
35  and  39  years  of  age,  one  case : 


44  Hugh  H.  Young. 

No.  137,  age  37,  had  never  had  gonorrhoea,  had  suffered  with  difficulty 
and  frequency  of  micturition  for  many  years.  The  prostate  was  not 
enlarged,  but  there  was  a  small  median  bar  and  440  cc.  residual  urine. 
Microscopically,  chronic  prostatitis. 

Forty-five  to  49  years  of  age,  three  cases : 

No.  37,  age  47.  History  of  gonorrhoea  and  stricture,  calculus,  duration 
12  years.  Catheter  life  two  years.  Small  median  bar,  microscopically, 
chronic  prostatitis. 

No.  8,  age  45  years.  No  history  of  gonorrhoea.  Urinary  difficulty  and 
frequency  for  two  years,  occasional  complete  retention  of  urine.  Prostate 
not  enlarged,  small  fibrous  median  bar.  Microscopically,  chronic  prostatitis. 

No.  133,  age  47.  No  history  of  gonorrhoea.  Frequency  of  urination  for 
10  years.  Complete  retention  of  urine  two  years  ago.  Residual  urine 
360  cc.  Prostate  not  enlarged,  soft,  small  median  bar.  Microscopically, 
chronic  prostatitis. 

Fifty  to  54  years  of  age,  9  cases : 

No.  90,  age  50.  Gonorrhoea.  Difficulty  of  urination  10  years.  Occasional 
complete  retention.  Prostate  very  little  enlarged,  small  round  pedunculated 
median  lobe.    Microscopically,  glandular  hypertrophy  with  prostatitis. 

No.  61,  age  50.  No  gonorrhoea.  Duration  of  urinary  symptoms  eight 
years.  Recent  complete  retention  of  urine.  Prostate  slightly  enlarged, 
a  small  median  lobe.  Microscopically,  glandular  hypertrophy  and  pros- 
tatitis. 

No.  102,  age  52.  No  gonorrhoea.  Urinary  frequency  and  pain  for  seven 
years.  Catheter  life  five  months.  Prostate  slightly  enlarged,  small  median 
bar.     Microscopically,  chronic  prostatitis. 

No.  143,  age  52.  History  of  gonorrhoea.  Frequency  of  urination  and  pain 
for  one  and  one-half  years.  Prostate  slightly  enlarged,  small  median  bar, 
large  vesical  diverticulum.     Microscopically,  chronic  prostatitis. 

No.  89,  age  53.  History  of  gonorrhoea  and  severe  stricture  for  30  years. 
Great  frequency,  difficulty  and  pain.  Contracted  bladder,  vesical  ulcer. 
Extensive  stricture  of  deep  urethra.  Small  hard  prostate,  slight  median 
bar.     Microscopically,  chronic  prostatitis. 

No.  66,  age  54.  Gonorrhoea.  Urinary  difficulty  and  frequency  for  several 
years,  previous  suprapubic  lithotomy.  Residual  urine  200  cc.  Slight  en- 
largement of  prostate,  small  median  bar.  Microscopically,  fibro  muscular 
hypertrophy. 

No.  17,  age  54.  No  history  of  gonorrhoea.  Difficulty  and  frequency  of 
urination  15  years.  Residual  500  cc.  Prostate  slightly  enlarged,  small 
pedunculated  median  lobe.  Residual  500  cc.  Microscopically,  glandular 
hypertrophy  with  chronic  prostatitis. 

No.  19,  age  54.  No  history  of  gonorrhoea.  Intermittent  severe  hematuria 
one  year.  No  difficulty  or  frequency  of  urination.  Residual  urine  220  cc. 
Considerable  hypertrophy  of  lateral  and  median  lobe.  Microscopically 
glandular  hypertrophy. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  45 

No.  82,  age  54.  Gonorrhoea  followed  by  stricture,  complete  retention  of 
urine,  catheter  life  for  eight  years.  Small  hard  prostate,  multiple  vesical 
diverticula,  severe  fibrous  stricture  of  the  deep  urethra,  small  median 
prostatic  bar.  Microscopically,  fibro  muscular  hypertrophy,  chronic  pros- 
tatitis. 

In  the  four  cases  younger  than  50  years  of  age  there  was  no  evi- 
dence of  glandular  proliferation  or  enlargement,  and  the  obstruction 
was  entirely  due  to  a  chronic  inflammatory  process  which  had  trans- 
formed the  median  portion  into  a  bar,  which  although  small  in  amount 
caused  very  serious  obstruction.  In  the  nine  cases,  between  the  ages 
of  50  and  54,  all  but  one  showed  evidence  of  chronic  inflammatory 
changes,  and  in  three  there  was  slight  evidence  of  glandular  prolifera- 
tion and  hypertrophy.  In  one  case  only  was  the  prostate  greatly 
enlarged,  and  in  this  case  there  was  considerable  hypertrophy  of  the 
lateral  lobes  and  a  large  pedunculated  median  lobe,  all  three  showing 
microscopically  a  pure  glandular  hypertrophy.  It  is  interesting  to 
note  that  in  this  case  there  was  no  urinary  disturbance,  the  only 
complaint  being  a  frequent  profuse  hematuria.  The  symptoms  pre- 
sented were  nothing  like  so  severe  as  with  the  small  inflammatory 
prostates  which  have  been  mentioned  above. 

A  review  of  these  cases  shows  conclusively  that  chronic  prostatitis 
may  lead  to  severe  obstructive  symptoms,  large  residual  urine,  multiple 
vesical  diverticula,  complete  retention  of  urine,  pain  and  great  dis- 
comfort, without  the  presence  of  any  definite  hypertrophy  of  the 
prostate. 

In  five  cases  only  was  there  a  history  of  gonorrhoea,  and  in  three 
of  these  stricture  of  the  urethra  was  present,  in  two  of  very  severe 
character  requiring  external  urethrotomy  and  excision  when  pros- 
tatectomy was  performed. 

In  all  of  the  13  cases  there  was  urgent  need  for  the  operation,  and 
the  splendid  results  which  have  been  obtained  justify  the  procedures 
undertaken. 

The  urine  was  infected  and  contained  pus  and  bacteria,  generally 
bacilli  in  11  of  the  12  cases  under  55  years  of  age.  All  of  these  11 
cases  showed  chronic  prostatitis.  The  one  case  in  which  the  urine  was 
sterile  showed  considerable  glandular  hjrpertrophy  and  no  prostatitis. 

The  cases  over  80  years  of  age  were  five  in  number,  viz.,  80,  81,  82,. 
82,  87.  In  three  cases  sjmaptoms  of  obstruction  had  only  been  present 
for  three  years  although  in  two  of  these  the  prostatic  enlargement  was 


46  Hugh  H.  Young. 

considerable.  In  one  case  (patient  age  82)  there  had  been  symptoms 
of  prostatic  obstruction  for  24  j-ears  and  the  prostate  was  so  huge 
that  it  could  be  felt  suprapubically  where  it  was  palpable  as  a  hypo- 
gastric tumor  four  inches  in  diameter.  The  tissue  removed  weighed 
340-G.  and  the  patient  is  now  well,  two  and  a  half  years  after  the 
operation,  and  is  85  years  old.  In  the  fifth  case  symptoms  had  been 
present  for  10  years  and  had  been  characterized  by  attacks  of  com- 
plete retention  of  urine  which  came  but  seldom,  the  rest  of  the  time 
there  being  little  disturbance. 

Maeital  State. — One  hundred  and  eleven  were  married,  19 
widowed,  12  were  single,  and  in  2  cases  no  note  was  made.  The  fact 
that  only  8.6%  of  these  144  cases  were  single  men  might  be  taken  at 
once  as  an  indication  that  prostatic  hypertrophy  is  one  of  the  uncom- 
fortable consequences  of  matrimony,  but  without  figures  at  hand  to 
show  what  percentage  of  men  over  50  years  of  age  remain  in  single 
blessedness,  it  is  impossible  for  me  to  judge  in  this  matter.  There  have 
been  many  to  assert  that  prostatic  hypertrophy  is  largely  due  to 
sexual  excesses,  and  were  it  possible  for  me  to  obtain  a  truthful  history 
as  to  the  sexual  habits  of  my  patients  it  might  be  possible  to  prove 
that  such  allegations  are  true. 

As  bearing  upon  this  subject  it  may  be  interesting  to  note  that 
there  is  not  a  single  case  in  my  series  in  which  the  patient  was  a 
Catholic  priest,  whereas  there  are  10  cases  in  which  the  patients  have 
been  Protestant  ministers  and  all  of  them  married. 

That  a  history  of  frequent  sexual  indulgence  is  not  a  necessary  pre- 
cedent I  know  from  a  few  cases  in  which  the  patient  distinctly  de- 
clared that  he  had  not  had  coitus  for  many  years  before  the  beginning 
of  his  prostatic  trouble. 

GoxoREHCEA. — Only  46  patients  admitted  having  had  gonorrhoea 
some  time  in  their  lives,  and  in  only  rare  instances  was  the  infection 
apparently  of  severe  character.  In  only  eight  of  the  144  cases  was 
there  stricture  present,  and  in  only  three  of  these  was  it  severe.  In 
four  cases  the  prostatic  trouble  seems  to  have  been  a  direct  continua- 
tion of  an  old  gonorrhoea,  but  in  the  remainder  of  the  cases  in  which 
gonorrhoea  had  been  present  there  is  nothing  to  show  that  it  had 
anything  to  do  with  the  onset  of  prostatic  hypertrophy.  In  fact, 
many  of  these  cases  in  which  gonorrhcea  at  some  previous  time  was 
acknowledged,  show  no  evidence  of  chronic  inflammatory  changes  in 


study  of  lJf.0  Cases  of  'Perineal  Prostatectomy.  47 

the  prostate,  and  it  therefore  seems  evident  that  gonorrhcea  cannot  be 
considered  as  an  etiological  factor  in  the  development  of  true  hyper- 
trophy of  the  prostate.  That  it  may  be  the  cause  of  a  chronic  pros- 
tatitis accompanied  by  marked  obstruction  to  urination  is  undoubtedly 
true,  but  that  it  is  not  the  sole  cause  or  in  fact  the  most  frequent  cause 
of  chronic  obstructive  prostatitis  is  demonstrated  by  this  series  of 
cases,  particularly  those  younger  than  55  years  of  age,  as  described 
above. 

We  may  add  in  passing  that  it  seems  clearly  proven  that  Ciechanow- 
ski's  assertion  that  nearly  all  cases  of  prostatic  hj-pertrophy  are  in- 
flammatory in  origin  is  absolutely  incorrect.  That  a  certain  amount 
of  inflammation  is  undoubtedly  present  in  many  of  the  cases  is  per- 
fectly true,  but  it  is  easy  to  explain  the  presence  of  prostatitis  when 
the  bladder  is  almost  invariably  infected  and  the  prostatic  urethra  is 
frequently  irritated  and  inflamed  by  the  passage  of  catheters  and 
infected  urine. 

Onset  and  initial  symptoms. — The  duration  of  time  which  had 
elapsed  since  the  onset  of  trouble  was  as  follows : 

One  year  or  less 6 

Between     1  and     2  years   19 

3  "       13 

4  "       8 

5  "        13 

6  "        15 

7  "        8 

8  "       7 

9  "       3 

10       "        16 

Between  11  and  15       "       24 

Between  16  and  20       "       6 

Between  21  and  25      "       2 

Between  26  and  30       "       2 

Not  noted  3 

In  reviewing  these  cases  one  is  struck  with  the  great  variations  as 
regards  duration  and  course  of  the  disease  presented.  In  108  cases 
the  time  elapsed  was  10  years  or  less  (70%),  and  in  45  cases  (30%) 
less  than  five  years  had  elapsed  since  the  beginning  of  the  trouble. 

In  six  cases  the  patient  had  noticed  nothing  unusual  until  the  pre- 
ceding year.  In  one  of  these  cases  (19)  there  was  no  urinary  dis- 
turbance,  the   only   complaint   being   intermittent   attacks   of   severe 


48  Hugh  H.  Young. 

hematuria.  On  examination  220  cc.  residual  urine  were  found  and  a 
considerable  enlargement  of  median  and  lateral  lobes.  In  another 
case  (138)  the  first  symptom  was  nocturnal  incontinence  six 
months  previously  and  up  to  time  of  admission  there  was  no  fre- 
quency or  difficulty  of  urination,  yet  the  catheter  found  890  cc. 
residual  urine  and  a  very  large  prostate  was  removed.  Three  cases 
(14,  27,  115)  had  occasional  complete  retention  of  urine  although 
there  had  been  no  symptoms  up  to  a  year  previously.  The  sixth  case 
(94)  had  a  small  cystin  calculus  and  a  pedunculated  median  lobe 
and  contracted  bladder,  but  had  never  used  the  catheter. 

In  10  cases  the  onset  of  the  disease  had  been  from  16  to  30  years 
before.  One  of  these  cases  (50),  age  71,  had  begun  to  have  difficulty 
of  urination  30  years  before,  but  the  disease  had  remained  stationary 
until  five  years  before,  when  he  was  catheterized  for  complete  retention 
of  urine.  On  entrance  he  was  voiding  urine  every  hour  with  consider- 
able difficulty  and  slight  pain,  but  did  not  require  a  catheter.  The 
prostate  was  small  and  soft  and  there  was  only  a  slight  median  bar,  but 
1100  cc.  residual  urine  was  present. 

Another  case  (137),  also  of  30  years'  duration,  was  only  37 
years  of  age,  and  at  the  age  of  seven  noticed  difficulty  and  frequency 
of  urination  which  persisted  up  to  time  of  admission.  The  prostate 
was  not  enlarged  and  there  was  only  a  small  median  bar  present,  but 
the  residual  urine  varied  from  400  to  600  cc.  and  the  catheter  was 
necessary  once  or  twice  daily. 

One  case  (89)  which  had  persisted  for  27  years  had  directly 
followed  stricture  of  the  urethra  due  to  gonorrhoea.  The  catheter  had 
been  necessary  at  times.  There  was  100  cc.  residual  urine,  a  con- 
tracted bladder  with  a  large  ulcer,  a  prostate  which  was  only  slightly 
enlarged,  with  a  small  median  bar  inflammatory  in  character. 

In  another  case  (16)  symptoms  of  frequency  and  difficulty  and 
occasional  complete  retention  had  been  present  for  25  years,  and 
suprapubic  drainage  had  been  necessary  one  year  previously.  The 
prostate  was  very  great  in  size,  the  tissue  removed  weighing  G-240. 

In  three  cases  (70,  84,  101)  the  onset  was  20  years  before,  and 
during  this  time  there  had  been  pain,  difficulty,  and  frequency  of 
urination. 

■  In  two  of  these  (70,  101)  calculi  were  present.  One  had  used 
a  catheter  for  nine  years,  and  one  year  previously  suprapubic  drain- 


study  of  llf.5  Cases  of  'Perineal  Prostatectomy.  49 

age  had  been  provided.  The  prostate  in  this  case  was  large  and 
adenomatous  in  type.  In  the  other  two  cases  (84,  101)  it  was  small 
and  inflammatory  in  type. 

One  patient  (120)  complained  only  of  painful  erections  which 
had  been  present  for  19  years,  and  to  relieve  which  he  found  it  neces- 
sary to  void  urine  several  times  during  the  night,  but  when  erections 
did  not  occur  he  would  sleep  all  night  without  urinating.  Urination 
was  somewhat  difficult  particularly  at  the  beginning  but  there  was  no 
increased  frequency  of  urination.  The  prostate  was  distinctly  en- 
larged and  the  cystoscope  showed  a  considerable  intravesical  hyper- 
trophy of  the  right  lateral  lobe,  which  was  removed  at  operation. 

One  case  (4)  had  begun  to  have  frequency  and  difficulty  of 
urination  17  years  before  and  during  the  last  five  years  frequently  re- 
quired catheterization.  The  prostate  was  only  moderately  hyper- 
trophied. 

The  last  case  (63)  in  which  the  symptoms  had  been  present  for 
16  years  had  had  complete  retention  of  urine  14  years  before,  and 
had  been  subjected  to  several  suprapubic  operations  for  calculus  and 
severe  hemorrhage  from  the  median  portion  of  the  prostate,  and  a 
suprapubic  drainage  apparatus  had  been  worn  for  seven  years.  A 
very  large  prostate  was  removed. 

The  onset  symptoms  were  as  follows : 

Frequency  of  urination  88   Cases. 

Difficulty  of  urination  78 

Pain  25 

Hematuria   7 

Complete  retention  of  urine 8 

Incontinence  of  urine 8 

Painful  erections  1 

Frequency  and  difficulty  of  urination,  as  shown  above,  are  by  far  the 
most  frequent  initial  symptoms  of  prostatic  hypertrophy  occurring  in 
60%  and  55%  of  the  cases  respectively.  At  the  beginning  both  of 
these  symptoms  are  as  a  rule  very  slight  in  character,  and  the  onset 
is  generally  so  gradual  that  it  is  difficult  for  the  patient  to  state  ex- 
actly when  urination  began  to  be  abnormal.  The  increase  in  fre- 
quency has  generally  been  recognized  first,  because  the  patient  had  to 
arise  once  or  twice  to  urinate,  and  in  many  instances  this  was  the 
only  symptom  for  a  considerable  period  of  time.  Difficulty  of  urina- 
tion has  generally  been  discovered,  first  because  the  patient  was  unable 


50  Hugh  H.  Young. 

to  start  the  floTV  of  urine  as  quickly  as  usual  when  the  desire  came  on. 
In  other  cases  the  patient  has  noticed  that  the  stream  was  definitely 
smaller  than  normal  and  that  force  was  required  to  void,  so  that  defi- 
nite obstruction  was  recognized^  but  in  a  great  many  cases  no  obstruc- 
tion has  been  appreciated  for  some  time  after  the  beginning  of  the 
disease. 

In  a  number  of  cases  the  frequency  and  difficulty  of  urination  have 
been  intermittent  in  character,  and  after  the  initial  attack  normal 
urination  has  followed  for  a  time. 

Pain. — Pain  has  been  noted  as  an  onset  symptom  in  25  cases.  In 
12  cases  there  was  only  a  slight  burning  in  the  urethra  during  urina- 
tion and  in  3  the  pain  was  merely  the  discomfort  produced  by  severe 
straining  to  void.  In  one  case  there  was  a  sharp  pain  which  followed 
sudden  stoppage  of  urine  during  micturition.  One  case  (5)  was 
characterized  by  a  severe  pain  which  came  on  at  the  beginning  of  uri- 
nation being  apparently  located  in  the  base  of  the  bladder,  but  rapidly 
radiating  from  there  upward  ''  along  the  course  of  the  ureter  and 
terminating  in  the  region  of  the  right  kidney^'  where  it  would  last 
with  considerable  intensity  for  three  minutes.  These  symptoms  which 
came  on  suddenly  persisted  for  one  month,  during  which  time  they 
recurred  with  each  urination,  they  were  finally  relieved  by  going  to 
a  mineral  spring  and  drinking  water  in  abundance.  Xo  calculus  was 
ever  passed  or  found  in  the  bladder. 

Eight  of  the  24  cases  complaining  of  pain  had  calculus  of  the  blad- 
der. In  two  cases  (3?,  122)  the  first  pain  was  a  severe  attack  of  pain 
in  the  back  (probably  renal  colic),  followed  by  vesical  pain,  due  to  the 
passage  of  stone  into  the  bladder.  In  six  of  the  cases  there  was  no 
pain  in  the  back  and  the  stone  was  probably  vesical  in  origin.  In 
three  calculus  cases  the  pain  at  onset  was  a  slight  smarting  during 
urination  located  in  the  urethra.  Two  of  the  calculus  cases  began 
witb  sudden  severe  pain  in  the  urethra,  but  in  another  case  there  was 
only  a  very  slight  irritation  at  the  neck  of  the  bladder. 

The  last  case  (47),  in  which  a  very  large  oxalate  calculus  was  after- 
wards removed,  the  onset  symptom  was  a  burning  sensation  in  the 
urethra  during  the  night,  and  a  slight  frequency  of  urination  during 
the  day,  10  years  before  admission.  Six  years  later  he  began  for  the 
first  time  to  get  up  at  night  to  urinate  and  after  that  urination  was 
very  frequent  during  the  day  but  there  was  no  pain  until  one  month 
before  admission,  and  then  onlv  a  slight  dull  feelinof  of  soreness  in 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  51 

the  urethra  during  and  after  urination.  There  was  never  any  severe 
pain  or  hematuria,  and  yet  at  operation  a  mulberry  calculus  with  very 
large  rough  spicules  and  about  6  cm.  in  diameter  was  removed.  The 
fact  that  there  was  only  15  cc.  residual  urine  and  a  bladder  which  was 
greatly  contracted  (capacity  50  cc.)  makes  the  absence  of  pain  all  the 
more  remarkable. 

One  case  (52)  began  with  pain  in  the  kidney  three  years  before  ad- 
mission. He  died  after  operation  and  autopsy  showed  double  pyone- 
phrosis. 

A  most  peculiar  case  (130)  was  one  of  considerable  prostatic  hyper- 
trophy in  which  the  onset  symptom,  and  in  fact  the  only  symptom 
during  the  19  years  preceding  his  admission  to  the  hospital  was  a 
severe  pain  in  the  perineum  and  deep  urethra  coming  on  at  night  and 
always  associated  with  erection  of  the  penis.  Although  the  prostate 
was  quite  large  there  was  never  any  difficulty  or  frequency  of  urina- 
tion, but  the  patient  would  have  to  arise  to  urinate  several  times 
almost  every  night  on  account  of  painful  erections,  and  it  was  on  this 
account  that  he  sought  relief. 

Hematuria. — This  was  present  as  an  onset  symptom,  as  stated 
above,  in  seven  cases.  Only  one  of  these  patients  suffered  with  cal- 
culus (case  23). 

In  one  case  (19)  without  previous  urinary  trouble  the  patient 
voided  several  large  clots  and  during  the  following  year  there  were 
five  attacks  of  painless  hematuria  during  which  much  blood  was  lost. 
On  admission  there  was  no  frequency  or  difficulty  of  urination,  but  a 
considerable  enlargement  of  both  lateral  and  median  lobes  was  present. 

In  another  case  (46)  there  were  two  hemorrhages  from  the  blad- 
der which  appeared  some  time  before  any  other  urinary  disturbance, 
but  did  not  reappear. 

In  two  cases  (20,  27)  there  was  hemorrhage  at  the  end  of  urination, 
which  reappeared  at  intervals  for  several  years  up  to  the  time  of 
operation. 

In  one  case  (16)  the  disease  began  with  hematuria  24  years  previous 
to  admission.  After  treatment  at  a  mineral  spring  the  blood  did  not 
appear  again. 

The  last  case  (84)  began  with  profuse  hematuria  and  a  diagnosis 
of  congestion  of  the  kidneys  was  made,  but  after  a  short  while  the 
hemorrhage  disappeared  and  did  not  reappear  during  the  20  years 
of  his  trouble. 


52  Hugh  H.  Young. 

It  seems  remarkable  that  hematuria  is  so  infrequent  in  cases  of 
prostatic  hypertrophy  which  were  associated  from  the  beginning  with 
vesical  calculus,  and  the  fact  that  in  the  seven  cases  detailed  above 
only  one  was  associated  with  calculus  shows  that  the  latter  has  very 
little  to  do  with  initial  hematuria.  Of  particular  interest  are  the 
cases  of  profuse  hematuria  recurring  at  intervals  (and  shown  later 
to  come  from  considerable  median  prostatic  enlargement),  but  en- 
tirely free  from  urinary  disturbance  of  a  serious  character. 

Complete  retention  of  urine. — This  has  been  the  first  symptom  in 
eight  cases.  One  case  (81)  had  complete  retention  of  urine  12  years 
before  admission  and  was  catheterized  for  two  days,  but  never  re- 
quired catheterization  afterwards.  The  second  case  (31)  had  com- 
plete retention  of  urine  five  years  before,  due  to  impaction  of  a 
small  calculus  in  the  urethra  which  was  passed  in  three  days.  The 
third  case  (14)  began  with  complete  retention  of  urine  and  required 
catheterization  at  intervals  afterwards.  The  fourth  case  (62)  began 
with  complete  retention  of  urine  three  years  before,  and  had  to  be 
catheterized  for  three  months,  but  was  never  catheterized  after  that. 
Th  fifth  case  (128)  began  with  complete  retention  of  urine  12  years 
before  and  required  catheterization  occasionally  afterward.  The  sixth 
case  (22)  began  with  complete  retention  10  years  before,  but  voided 
without  catheterization.  Por  two  years  before  admission  the  catheter 
was  used  daily  on  account  of  incomplete  retention.  The  seventh  case 
(139)  began  with  complete  retention  10  years  before  but  was  relieved 
by  medicines  internally  and  began  the  use  of  the  catheter  again  only 
five  weeks  before  admission  (on  account  of  incomplete  retention) .  The 
eighth  case  (8)  began  with  complete  retention  of  urine  during  typhoid 
fever  and  was  catheterized  for  several  weeks.  Afterwards  the  patient 
was  catheterized  occasionally  owing  to  complete  retention  or  dhficult 
urination. 

It  will  be  noted  that  in  none  of  these  cases  did  retention  of  urine 
ever  become  permanently  complete,  and  in  fact  it  is  remarkable  that 
the  subsequent  course  was  characterized  by  less  use  of  the  catheter 
than  is  usually  present  in  most  cases  of  prostatic  hypertrophy.  It  is 
also  interesting  to  note  that  in  four  of  these  cases  the  complete  reten- 
tion of  urine  came  on  10  years  or  more  before  admission  to  the  hos- 
pital, and  yet  none  of  these  cases  became  dependent  upon  the  catheter. 

Incontinence  of  urine. — As  mentioned  above  this  occurred  in  eight 
cases  as  an  onset  symptom,  but  in  two  of  these  there  was  merely  a 


study  of  145  Cases  of  'Perineal  Prostatectomy.  53 

slight  dribbling  of  urine  at  the  end  of  micturition.  In  three  cases, 
however  (28,  136,  138),  the  only  symptom  was  nocturnal  incontinence 
of  urine  which  occurred  every  night,  and  was  not  associated  with  any 
frequency  or  difficulty  of  urination.  In  one  case  this  was  present  for 
three  years,  when  complete  retention  of  urine  came  on  and  catheter 
life  was  begun.  In  the  second  case  (136)  it  persisted  as  the  only 
symptom  during  the  two  years  previous  to  admission,  and  in  the  third 
case  (138)  it  had  been  the  only  symptom  present  for  six  months  pre- 
vious to  admission. 

All  of  these  cases  were  similar  in  having  no  frequency  or  difiBculty 
of  urination  and  no  incontinence  by  day.  Two  were  catheterized  for 
the  first  time  in  the  hospital  and  580  and  600  cc.  residual  urine  re- 
spectively was  withdrawn. 

The  sixth  case  (3)  was  associated  with  tabes  dorsalis  and  came  on 
with  frequency  and  difficulty  of  urination,  and  nocturnal  incontinence 
of  urine  14  years  before  admission.  These  symptoms  persisted  for 
three  months,  when  he  was  catheterized  by  a  physician  and  after  that 
was  unable  to  void  and  led  a  catheter  life  for  14  years.  (It  is  inter- 
esting to  note  that  natural  urination  at  normal  intervals  was  estab- 
lished in  this  case  by  removal  of  the  prostate,  which  was  moderately 
but  definitely  hypertrophied.) 

The  seventh  case  (119)  began  two  years  before  admission  with  occa- 
sional incontinence  of  urine  during  the  day  and  a  feeling  of  pressure 
in  the  bladder,  but  with  no  difficulty  or  frequency  of  urination.  There 
was  also  marked  impairment  of  sexual  powers  and  of  the  knee-jerks. 
He  was  catheterized  and  led  a  catheter  life  afterwards.  After  pros- 
tatectomy the  incontinence  persisted  and  girdle  pains  and  other  symp- 
toms of  spinal  disease  showed  themselves. 

The  eighth  case  (100)  began  with  incontinence,  difficult  and  painful 
urination  eight  years  before  admission.  The  incontinence  persisted 
for  only  a  few  weeks. 

Eemarhs. — A  study  of  these  eight  cases  with  incontinence  as  an 
onset  symptom  shows  that  with  exception  of  two  cases  the  disease  was 
due  to  over-distention  of  the  bladder  and  not  to  spinal  disease,  and 
the  fact  that  they  have  been  cured  by  prostatectomy  shows  that  this 
symptom  is  no  contraindication  to  operation.  The  incontinence  is 
probably  due  to  the  peculiar  disposition  of  the  prostatic  enlargement 
at  the  vesical  orifice  leaving  an  opening  through  which  the  urine  can 
continuously  escape,  but  why  the  external  sphincter  does  not  prevent 


54  Hugh  H.  Young. 

the  incontinence  is  to  me  inexplicable,  in  view  of  the  fact  that  after 
suprapubic  prostatectomy  the  prostatic  orifice  is  often  very  greatly 
dilated,  and  yet  incontinence  very  seldom  occurs. 

B.    STATUS  PR^SENS. 

The  symptoms  present  on  admission  were  as  follows : 

a.  Pain,  slight    16   Cases. 

considerable 61 

&.  Hematuria,  slight    7 

considerable    15 

c.  Difficulty  of  urination,  slight 10 

considerable 78 

d.  Incontinence  of  urine 6 

e.  No  increase  in  frequency  or  difficulty  of  urination 3 

f.  Frequency  of  urination,  95  cases  in  which  the  interval  be- 

tween urinations  was  less  than  i/^  hour    in 7 

Between  y^  and  1  hour    in 25 

1  hour    in 37 

2  hours  in 19 

3  hours  in 7 

a.  Pain. — As  shown  above,  pain  has  been  present  in  over  50%  of 
the  cases.  In  some  of  the  cases  it  was  very  slight,  and  evinced  itself 
as  a  burning  or  aching  pain  in  the  deep  urethra  and  generally  worse 
during  urination.  In  the  majority  of  cases,  however,  it  was  fairly 
considerable  and  was  characterized  by  pain  which  began  in  the  neck 
of  the  bladder  just  before  urination  and  radiated  from  there  to  the 
end  of  the  penis.  In  some  instances  this  pain  was  very  severe  and 
was  accompanied  by  marked  vesical  tenesmus,  straining  and  abdominal 
spasm,  this  was  particularly  true  in  20  cases  associated  with  calculus 
in  the  bladder,  but  there  were  many  other  cases  in  which  the  pain  was 
just  as  severe  in  which  no  calculus  was  present.  In  a  number  of  these 
cases  a  severe  pain  radiating  to  the  end  of  the  penis  and  felt  most 
severely  just  behind  the  glans,  and  which  is  considered  almost  patho- 
gnomonic of  vesical  calculus  was  present.  This  severe  pain  without 
the  presence  of  calculus  was  frequently  due  to  cystitis  and  was  often 
associated  with  vesical  contracture.  In  other  cases,  however,  it  was 
associated  with  considerable  distention  of  the  bladder  and  a  large 
residual  urine.  In  some  instances  the  pain  came  on  when  the  bladder 
became  full  and  completely  disappeared  after  catheterization,  but  in 
several  cases  the  catheter  afforded  no  relief.     One  of  these  patients 


study  of  14-5  Cases  of  'Perineal  Prostatectomy.  55 

(54)  catheterized  himself  13  times  a  day.  The  bladder  was  con- 
tracted and  considerably  inflamed,  but  there  was  no  stone  found  and 
natural  urination  has  been  established  by  prostatectomy.  Another 
such  case  (10)  voided  urine  every  two  hours  with  great  pain  and 
difficulty.  There  was  only  100  cc.  residual  urine  and  the  bladder  was 
markedly  contracted,  but  no  calculus  was  present.  Another  case  (117) 
voided  urine  every  half  hour  with  great  pain,  but  there  were  only  80 
cc.  residual  urine  present,  and  no  calculus.  Several  cases  in  which 
the  prostate  was  not  enlarged  except  in  the  shape  of  a  small  median 
bar  and  in  whom  the  microscope  showed  chronic  prostatitis,  belonged 
to  these  cases  of  frequent  and  painful  urination  with  contracture  of 
the  bladder  and  little  residual  urine. 

Two  cases  in  which  calculi  were  found  were  remarkable  for  the 
absence  of  pain.  One  (23)  had  a  calculus  about  2  cm.  in  diameter, 
but  the  bladder  was  very  greatly  distended,  holding  2000  cc.  residual 
urine.  In  the  other  (47)  the  bladder  was  greatly  contracted  and  there 
was  very  little  residual  urine  and  the  stone  was  very  large,  and  it  is 
difficult  to  explain  the  absence  of  pain.  In  several  cases  the  patient 
complained  of  a  dull  aching  pain  in  the  back,  and  in  four  cases  there 
was  definite  evidence  of  renal  infection  and  a  suggestion  of  renal  cal- 
culus. A  slight  dull  aching  pain  in  the  rectum  was  not  an  uncommon 
symptom  and  appeared  most  frequently  during  and  after  defecation, 
but  in  only  a  few  cases  (notably  cases  114,  28)  was  there  a  severe 
aching  pain  present  in  the  rectum.  In  both  of  these  large  vesical 
calculi  were  present. 

In  one  case  ( 5 ) ,  mentioned  before  when  discussing  onset  symptoms, 
the  pain  began  in  the  bladder  and  radiated  to  the  kidney.  One  case 
(130)  was  remarkable  on  account  of  very  severe  pain,  which  was 
located  in  the  lumbar  region  of  the  spine  and  was  accompanied  by 
paroxysms  of  excruciating  pain  which  occurred  at  frequent  intervals 
and  were  provoked  by  movements  of  any  sort.  A  spinal  tumor  was 
suspected  but  no  other  symptoms  suggesting  it  were  present. 

Remark. — In  reviewing  the  occurrence  of  pain  in  these  145  cases 
of  benign  prostatic  hypertrophy  one  is  struck  by  the  fact  that  it  is 
limited  almost  entirely  to  the  region  of  the  bladder  and  urethra,  and 
in  almost  all  cases  is  intermittent  in  character,  coming  on  generally  as 
the  bladder  becomes  full,  generally  increasing  during  urination  and 
sometimes  being  very  severe  at  the  end.     A  pain  radiating  to  the 


56  Hugh  H.  Young. 

end  of  the  penis,  which  is  considered  so  suggestive  of  stone,  is  often 
seen,  without  the  presence  of  calculus,  and  simply  means  that  spas- 
modic pain  originating  in  the  prostate  is  generally  referred  down  the 
urethra  and  most  often  to  the  end  of  the  penis. 

It  is  interesting  to  note  that  the  pains  presented  in  these  cases  are 
entirely  different  from  those  generally  seen  in  cases  of  carcinoma  of  the 
prostate,  in  which  pain  is  a  very  much  more  prominent  symptom,  is 
often  almost  constantly  present  as  a  dull  or  severe  aching  in  the  pros- 
tate, rectum  and  perineum,  and  in  the  more  advanced  cases  is  asso- 
ciated with  severe  pain  in  the  back,  buttocks,  thighs,  and  legs  follow- 
ing the  course  of  the  pelvic  nerves. 

h.  Hematuria. — As  stated  above  this  was  present  in  22  cases  (15%), 
but  in  seven  cases  was  slight.  It  is  interesting  to  note,  that  in  the 
24  cases  which  were  associated  with  vesical  calculus,  hematuria  was 
present  in  only  seven  cases.  Among  the  17  cases  in  which  it  was 
absent  were  three  cases  in  which  very  large  calculi  were  found,  and  in 
the  other  cases,  from  one  to  seven  calculi  were  present,  and  of  varying 
size  and  character.  In  many  of  these  cases  the  bladder  was  contracted 
so  that  one  would  have  expected  hematuria  as  a  result  of  the  calculi 
being  forced  against  the  prostatic  orifice  at  the  end  of  urination,  but 
such  was  not  the  case.  In  the  five  cases  in  which  hemorrhage 
was  a  conspicuous  feature  of  the  disease,  calculi  were  not  present 
(cases  19,  74,  27,  63,  11). 

It  is  interesting  to  note  also  that  in  none  of  these  cases  was  a 
catheter  used,  the  hemorrhage  coming  on  spontaneously  and  without 
apparent  reason.  In  two  cases  (19,  11)  in  which  the  hemorrhage 
was  very  marked,  urination  was  almost  normal  and  there  was  little  or 
no  residual  urine,  and  in  another  case  (63)  in  which  very  alarming 
hemorrhages  occurred,  constant  suprapubic  drainage  was  present  and 
there  was  no  traumatism  and  no  vesical  spasm  to  account  for  the 
hemorrhage.  These  three  cases,  however,  were  each  associated  with 
considerable  intravesical  prostatic  hjrpertrophy. 

c.  Difficulty  of  urination. — The  10  cases  in  which  the  difficulty  of 
urination  was  described  as  slight  comprise  very  interesting  cases. 
In  three  cases  there  was  over  1000  cc.  residual  urine  (44,  30,  107)  and 
neither  of  these  patients  had  been  catheterized.  One  was  associated 
with  a  very  large  diverticulum  of  the  anterior  wall  of  the  bladder. 
One  (94)  had  calculus.     One  (19)  had  had  severe  attacks  of  hema- 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  57 

turia.  One  (5)  suffered  severe  pain  in  bladder  and  kidney,  and  two 
cases  in  which  small  median  lobes  were  present  occasionally  had  com- 
plete retention  of  urine.  One  ( 143 )  voided  with  ease  at  fairly  normal 
intervals  and  there  were  only  65  cc.  residual  present,  but  the  cystoscope 
showed  a  fairly  large  diverticulum  (which  had  dragged  the  left  ureter 
into  this  orifice)  and  other  evidences  of  considerable  intravesical  ob- 
struction. 

In  78  cases  there  was  considerable  or  very  great  difficulty  of  urina- 
tion, and  many  of  these  cases  used  a  catheter  more  or  less  frequently 
to  obtain  comfort.  In  a  number  of  instances  efforts  at  urination 
were  attended  with  very  great  difficulty,  severe  spasm  of  the  abdomen 
and  bladder,  and  not  infrequently  compulsory  defecation  so  that  it 
was  necessary  for  the  patient  to  go  to  stool  every  time  the  desire  to 
urinate  came  on  (and  this  very  frequently). 

In  many  cases  although  the  prostate  was  considerably  enlarged,  and 
a  large  amount  of  residual  urine  was  present,  micturition  was  not 
very  difficult  or  frequent,  and  had  it  not  been  for  the  discomfort  of  a 
distended  abdomen,  slight  pain  and  occasionally  hematuria,  the  patient 
would  probably  not  have  sought  operative  relief.  A  number  of  the 
cases  presented  great  variability  as  to  the  difficulty  of  urination,  at 
times  going  several  weeks  with  almost  normal  urination,  when  sud- 
denly an  attack  of  difficulty,  frequency  and  pain  on  urination  would 
come  on  without  apparent  cause,  and  not  infrequently  requiring 
catheterization. 

d.  The  six  cases  of  drihhling  of  urine  have  been  spoken  of  be- 
fore (see  onset  symptoms).  With  one  exception  they  were  all  char- 
acterized by  a  greatly  distended  bladder  which  had  never  been  cathet- 
erized.  In  one  case  (84)  the  bladder  was  contracted,  irritable,  there 
was  only  250  cc.  residual  urine,  and  the  prostate  was  of  the  small 
inflammatory  type. 

e.  The  three  cases  in  which  there  was  no  difficulty  of  urination 
were  each  characterized  by  considerable  enlargement  of  the  prostate, 
and  in  two  cases,  both  of  which  had  never  been  catheterized  (cases 
118,  138)  there  was  660  cc.  and  890  cc.  residual  urine  respectively 
present,  and  both  suffered  from  nocturnal  incontinence  of  urine. 
The  third  case  (120)  showed  35  cc.  residual  urine,  but  the  bladder 
was  trabeculated  and  contracted.  The  only  complaint  was  pain  in 
the  perineum,  associated  with  frequent  erections  at  night. 

Vol.  XIV.— 5. 


58  Hugh  H.  Young. 

Sexual  Powers. 
The  following  tabulation  gives  the  condition  as  regards  presence  of 
erections  and  indulgence  in  sexual  intercourse  on  admission.     The 
eases  have  been  grouped  according  to  age  as  follws : 

Erections.  Under  50  yrs.     60  to  59  60  to  69  TO  to  79  80  to  90 

Present    5   Cases.     21   Cases.  30   Cases.  9   Cases.  0   Cases. 

Impaired    0       "  3       "  13       "  4       "  0       " 

Not  present 0       "  3       "  14       "  15       "  2       " 

Not  noted 0       "  5       "  9       "  12       "  3       " 

Sexual  Intercourse. 

Normal    4   Cases.     17   Cases.     17   Cases.  4  Cases.  0  Cases. 

Impaired    0      "            5      "          11      "  0      "  0      " 

Not  performed   ....  0      "            1      "          14      "  15      "  0      " 

Painful   0      "            1      "            3      "  0      "  0      " 

Not  noted 1       "            5       "          11      "  14       "  4       " 

According  to  the  above  figures  the  sexual  powers  in  patients  under 
50  years  of  age  were  normal  in  100%  of  the  cases. 

Between  50  and  60  years  of  age,  erections  were  normal  in  78%  of 
the  cases  noted,  and  present  but  impaired  in  11%,  and  coitus  was 
normal  in  74%  of  the  cases  noted,  and  present  but  impaired  in  21%. 

Between  the  ages  of  60  and  69,  erections  were  normal  in  55%  of  the 
cases,  and  impaired  in  25%.  Coitus  was  normal  in  38%.,  and  present 
but  impaired  in  32%. 

Between  the  ages  of  70  and  79,  erections  were  present  in  32%  of 
those  noted,  and  impaired  in  14%.     Coitus  was  normal  in  21%. 

Catheter  Life, 
a.  Complete  retention  of  urine  occurred  at  some  time  in  64  cases, 
and  required  the  use  of  the  catheter.     The  time  at  which  this  occur- 
red was  as  follows: 

Less  than  1  month  before  admission 13   Cases. 


Between  1  and  6  months 

1  year 

2  years 

3  years 

4  years 

5  years 

6  to  10  years 
14  years 


6 
7 

13 
7 
1 
5 

11 
1 


Time  not  noted  1 

Total    cases    with    complete    retention    at 

some  time    65 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  59 

&.  No  attack  of  complete  retention,  45  cases. 

c.  No  catheterization  for  any  cause,  20  cases. 

d.  The  catheter  had  been  employed  more  or  less  regularly  for  in- 
complete retention  of  urine  in  70  cases,  as  folloTvs : 

Less  ttLan  1  month  9   Cases. 

Between  1  and  6  months 20      " 

1  year     9 

2  years    8      " 

3  "         4       " 

5  "         3       " 

7  "         1       " 

8  "         2       " 

9  "         2       " 

12      "         1       " 

14      "         1       " 

16      "         1       " 

Time  not  noted   9       " 

e.  The  patient  led  a  catheter  life,  retention  of  urine  being  complete 
in  35  cases,  as  follows : 

Less  than  1  month  12   Cases 

Between  1  and  6  months 2      " 

1  year     5      " 

2  years    6 

3  "        2       " 

4  "        1       " 

6  "        1       " 

7  "         1       " 

8  "         2       " 

9  "        1       " 

14      "         1       " 

Not  noted    1      " 

/.  In  these  35  cases  in  which  retention  of  urine  was  complete  (e) 
the  catheter  was  employed  by  the  patient  when  admitted  to  hospital 
at  the  following  interyals  daily. 

2  hours    1  Cases. 

3  "        2 

4  "        3 

5  times  daily    5 

4       "  "        9 

3       "  "        6 

2       "  "        3 

Occasionally  complete   5 

Not  noted 1 


60 


Hugh  H.  Young. 


g.  In   55   cases  the  retention  of  urine  was   incomplete,  but  the 
catheter  was  employed  at  the  following  intervals  daily : 


2  hours   

1  Cases 

4       "       

2 

5  times  daily    

4      "           "       

2      " 

3 

3      "          "       

6 

2       "           "        

20       " 

1       "           "        

8 

Occasionally    

Not  noted 

11       " 

2       " 

h.  The  catheter  had  never  been  used  in  31  cases. 
i.  In  cases  it  was  not  being  used  on  admission  to  hospital  al- 
though it  had  been  necessary  at  some  previous  time  owing  to  one  or 
more  attacks  of  retention  of  urine. 

j.  In  seven  cases  suprapubic  fistulse  were  present,  and  no  urine 
came  through  the  urethra. 

]c.  In  three  cases  the  urine  passed  through  a  retained  catheter  in 
the  urethra. 

Z.  In  two  cases  catheterization  was  impossible  and  suprapubic  aspi- 
ration was  employed. 

w.  The  amount  of  residual  urine  found  with  a  catheter  was  as  fol- 
lows: 

Less  than  50  cc 11   Cases. 

Between  50  and  100  cc 16 

100  cc 13 

150  cc 7 

200  cc 10 

250  cc 11 


300  cc. 

350  cc. 

400  cc. 

500  cc. 

600  cc. 

660  cc. 

890  cc. 

940  cc. 
1000  cc. 
1100  cc. 
1150  cc. 
1200  cc. 
2000  cc. 


study  of  145  Cases  of  'Perineal  Prostatectomy. 


61 


n.  The  bladder  capacity  on  examination  was  found  to  be  as  follows : 

50  cc 4   Cases. 

100  cc 3      " 

150  cc 14 

200  cc 11      " 

250  cc 16 

300  cc 22 

400  cc 54       " 


500  cc. 

600  cc. 

700  cc. 

800  cc. 

900  cc. 
1000  cc. 
1100  cc. 
1200  cc. 
2000  cc. 


0.  In  35  cases  with  calculus  present  the  residual  urine  and  bladdei 
capacity  was  as  follows : 


Less  than      50  cc 

Retention  inc 
R.  U. 

5   Cases. 

omplete. 
B.C. 

2   Cases 

Retention 

complete. 

B.C. 

50  cc 

2 

100  cc 

4       " 

3 

1   Case 

150  cc 

3 

3 
3 

1 

200  cc 

4       " 

250  cc 

4 

400  cc 

2       " 

2 

1      " 

500  cc 

2 

2000  cc 

1       " 

1       " 

Suprapublic  fistula  325  cc 

1      " 

Tlie  Condition  of  Patient  at  Time  of  Operation. 

As  bearing  somewhat  upon  the  condition  of  the  patient  it 
will  be  interesting  to  refer  to  the  table  of  ages,  which  shows  that  45 
cases  were  over  70  years  of  age  (31%)  and  that  16  cases  were  be- 
tween 75  and  79  years  of  age,  four  between  80  and  84  years  of  age, 
and  one  87  years  of  age.  Eighteen  cases  were  described  as  being  in 
a  very  weak  condition,  and  one  of  these  had  developed  the  morphia 
habit.  In  seven  cases  there  was  marked  emphysema  of  the  lungs. 
Arteriosclerosis  was  a  very  common  finding,  but  in  six  cases  it  was 
very  marked,  and  in  one  case  was  associated  with  severe  attacks  of 


62  Hugh  H.  Young. 

angina  pectoris  (67),  and  in  another  case  with  hemiphlegia  (91). 
In  32  cases  heart  murmurs  and  other  evidence  of  old  endocarditis  were 
present,  and  in  eight  cases  the  heart  was  enlarged  although  no  mur- 
murs were  heard.  In  many  cases  the  heart  was  well  compensated, 
but  in  several  instances  there  was  considerable  lack  of  compensation, 
and  the  condition  of  the  heart  was  serious.  Two  of  the  fatal  cases 
were  classed  among  these. 

There  was  definite  kidney  infection  in  six  cases  (69,  109,  24,  75, 
70,  52)  and  in  two  cases  nephrolithiasis. 

Five  patients  were  suffering  from  uremia,  in  two  cases  of  a  very 
severe  type  and  associated  with  considerable  fever  (109,  52). 

Urinayses. — The  urine  was  of  low  specific  gravity  and  of  low  area 
content  in  so  many  cases  that  it  is  impossible  to  say  just  how  many 
were  suffering  from  definite  nephritis. 

That  a  great  many  cases  were  complicated  with  more  or  less  severe 
kidney  lesions  is  undoubtedly  true.  The  correct  estimation  of  albu- 
min and  the  finding  of  casts  was  interfered  with  in  most  cases  by  the 
large  amount  of  pus  present,  but  in  10  cases  granular  casts  were 
found,  and  they  were  probably  present  but  not  detected  in  many 
others. 

In  one  case  (20)  there  was  complete  suppression  of  urine  before  the 
operation,  and  in  three  other  cases  nausea  and  vomiting  with  other 
symptoms  of  uremia. 

The  urine  was  acid  in  111  cases  and  alkaline  in  14,  and  neutral  in 
five  cases.  It  was  clear  and  contained  no  pus  in  eight  cases.  Pus  was 
present  and  noted  in  126  cases,  and  in  13  cases  the  presence  of  casts  was 
noted. 

In  most  cases  the  urine  was  examined  immediately  after  voiding  in 
a  clean  vessel,  a  stained  specimen  being  made  after  centrifugalizing. 
In  53  cases  bacilli  of  the  colon  type  were  present.  In  14  cases  cocci, 
probably  staphylococci,  were  present.  In  18  cases  the  urine  was 
sterile,  no  bacteria  being  found  after  careful  examination.  In  13 
cases  bacteria  were  found,  but  the  character  was  not  noted. 

Epididymitis. — Epididymitis  had  been  present  at  some  time  before 
operation  in  29  cases  (20%).  In  19  cases  it  was  single  and  in  10 
cases  both  sides  were  involved.  In  three  cases  acute  epididyraitis  was 
present  at  the  time  of  operation. 

Hernia. — Hernia  were  present  in  16  cases,  single  in  11  and  double 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  63 

in  5,  all  in  the  inguinal  region.  One  case  also  had  a  ventral  hernia 
following  suprapubic  prostatectomy. 

Hemorrhoids  were  frequently  present  and  generally  gave  no  trouble 
after  the  prostatic  obstruction  had  been  removed. 

Stricture  of  Urethra. — Definite  stricture  of  the  urethra  was  present 
in  eight  cases.  In  two  cases  (82  and  89)  dense  hard  strictures  of 
small  caliber  were  present  in  the  bulbo  membranous  region.  Three 
cases  (141,  133,  73)  had  strictures  of  the  bulbous  urethra 
of  large  caliber,  but  in  the  last  case  quite  fibrous  in  type.  In  three 
cases  (95,  55,  53)  strictures  of  the  pendulous  urethra  were  present, 
and  in  two  cases  were  quite  fibrous  and  required  dilatation.  It  is 
probable  that  strictures  of  large  caliber  were  present  in  other  cases, 
but  as  a  careful  examination  of  the  anterior  urethra  with  bougies-a- 
boule  was  not  made  a  routine  procedure,  some  cases  may  have  been 
overlooked.  A  careful  examination  for  strictures  should  always  be 
made  as  their  presence  has  much  to  do  with  the  closure  of  perineal 
fistula  after  prostatectomy,  which  fact  a  study  of  the  above  cases 
forcibly  brought  out. 

Previous  operations. — A  Bottini  operation  had  been  performed  in 
six  cases,  four  by  myself.  These  cases  are  of  interest.  Case  I  (108) 
had  considerable  enlargement  of  both  median  and  lateral  lobes.  Two 
attempts  were  made  to  perform  the  Bottini  operation,  but  both  were 
unsuccessful  owing  to  the  burning  out  of  the  electrical  transformer 
which  was  used  in  this  particular  hospital  (not  the  Johns  Hopkins). 
This  is  the  only  case  in  which  this  accident  happened  in  my  practice. 

Case  II  (11),  characterized  by  two  very  large  lateral  lobes,  was 
completely  relieved  of  all  urinary  obstruction  and  urinary  frequency 
by  the  operation,  but  began  to  have  severe  hemorrhages  one  year  later 
and  perineal  prostatectomy  was  performed  to  remove  the  very  large 
intravesical  lobes  and  the  bleeding  ceased. 

Case  III  (24)  had  a  small  median  lobe,  a  contracted  bladder  and 
little  residual  urine,  and  was  not  improved  by  the  Bottini  operation. 

Case  IV  (145)  was  exactly  similar  to  case  III. 

Case  V  (71)  had  been  subjected  to  two  Bottini  operations  and  one 
perineal  prostatectomy  in  Germany  without  success.  An  examination 
showed  a  small  globular  median  lobe. 

Case  VI  (9)  had  had  three  Bottini  operations  and  suprapubic 
drainage. 


64  Hugli  H.  Young. 

Suprapubic  prostatectomy  had  been  previously  performed  in  two 
cases  (by  others)  with  unsuccessful  results.  In  both  of  these  cases 
(83,  116)  considerable  enlargement  of  the  prostate  remained. 

Perineal  prostatectomy  had  been  performed  in  one  case  mentioned 
above. 

Castration  had  been  performed  in  three  cases  (24,  25,  145),  in  all 
with  unsatisfactory  results.  In  two  cases  perineal  prostatectomy 
showed  the  lateral  lobes  very  little  enlarged  and  possibly  atrophic,  but 
an  obstructing  median  bar  was  present.  In  the  third  case  the  pros- 
tate was  very  large  and  showed  not  the  slightest  evidence  of  atrophy. 

Suprapubic  drainage  had  been  supplied  in  eight  cases,  and  the  pa- 
tients wore  some  form  of  drainage  apparatus  on  admission  to  the  hos- 
pital, and  were  unable  to  void  through  the  urethra. 

Suprapubic  lithotomy  had  been  employed  in  one  case  and  was  fol- 
lowed by  closure  of  the  bladder.  In  three  of  the  cases  in  which  the 
sinus  persisted  calculi  had  been  present. 

Litholapaxy  had  been  performed  several  years  previously  in  one 
case. 

'Perineal  section  on  account  of  stricture  of  the  urethra  had  been 
performed  in  two  cases  (89,  82).  In  both  of  these  cases  very  severe 
urethral  strictures  were  present  and  the  prostatic  obstruction  was 
inflammatory  in  type. 

The  Character  of  Prostatic  Enlargement. 

Rectal  examination. — The  size  of  the  prostate  as  determined  by 
rectal  examination  was  as  follows :  Apparently  not  enlarged,  4  cases ; 
slightly  but  definitely  enlarged,  36  cases;  moderately  enlarged,  50 
cases ;  considerably  enlarged,  52  cases ;  very  greatly  enlarged,  two  cases ; 
huge,  one  case. 

The  exact  description  of  the  size  of  a  prostate  as  felt  by  rectal  ex- 
amination is  always  difficult,  and  I  have  as  yet  found  no  satisfactory 
method  of  stating  the  size  that  I  think  a  prostate  is,  on  rectal  exami- 
nation. In  almost  all  of  these  145  cases  the  record  of  examination 
is  my  own,  so  that  variations  which  may  arise  when  examinations  are 
made  by  numerous  observers  is  largely  eliminated. 

The  facility  with  which  a  prostate  may  be  felt  in  a  given  case  has 
much  to  do  with  the  impression  one  gets  of  its  size,  e.  g.,  in  a  very 
thin  person  with  a  slight  amount  of  perineal  tissue  the  prostate  usually 


study  of  IJi-o  Cases  of  'Perineal  Prostatectomy.  65 

seems  larger  than  in  cases  in  vrhicli  the  perineum  is  fatty  and  the 
prostate  difficult  to  reach. 

The  four  cases  in  which  the  prost-ate  was  apparently  not  enlarged 
were  shown  with  the  cystoscope  to  have  definite  enlargement  of  the 
median  portion  (bar  or  lobe),  and  in  many  of  the  cases,  in  which  the 
enlargement  was  described  as  slight,  the  obstruction  was  largely  of 
this  t}"pe,  but  although  these  cases  showed  only  a  slight  hypertrophy 
of  the  prostate  they  were  accompanied  by  symptoms  sufficiently  severe 
to  require  relief,  and  in  many  instances  the  obstruction  was  as  com- 
plete as  with  some  of  the  largest  prostates.  In  this  series  of  cases  it 
was  shown  conclusively  that  cystoscopic  examination  was  absolutely 
necessary  to  determine  the  cause  of  the  obstruction,  for  in  many  of 
these  small  prostates  one  would  not  have  been  justified  without  cysto- 
scopic examination  in  saying  that  the  prostate  was  responsible  for  the 
symptoms  and  obstruction  present. 

In  many  of  the  larger  prostates  the  rectum  was  considerably  im- 
pinged upon  by  the  prostatic  mass  and  in  some  cases  very  little  space 
was  left  between  the  posterior  surface  of  the  prostate  and  the  sacrum. 
^Many  of  these  cases  suffered  with  considerable  bowel  obstruction, 
chronic  constipation,  and  in  some  cases  defecation  was  not  only  difficult 
but  painful.  It  is  remarkable,  however,  that  pain  in  the  rectum  was 
notable  particularly  for  its  absence,  thus  differentiating  these  cases 
from  the  malignant  prostates. 

Surface. — The  posterior  surface  of  the  prostate  was  described  as 
irregular  in  14  cases  and  nodular  in  one.  This  irregularit}-  usually 
consisted  in  the  presence  of  one  or  two  prominent  lobules  which  pro- 
jected from  the  general  level  of  the  prostate.  In  four  or  five  in- 
stances it  seemed  as  if  a  small  lobule  of  gland  tissue  had  broken 
through  the  capsule  and  developed  extraprostatically  (so  to  speak). 
This  was  most  commonlv  present  at  the  upper  end  of  one  of  the 
lateral  lobes,  by  the  side  of  the  ejaculatory  duct,  where  the  capsule  is 
known  to  be  least  dense. 

In  other  cases,  however,  the  surface  of  the  prostate  was  distinctly 
irregular.  This  irregularity  was  most  common  at  the  upper  end  of 
one  or  both  of  the  lateral  lobes,  and  was  usually  associated  with  a  cer- 
tain amount  of  chronic  prostatitis  and  seminal  vesiculitis.  Occasion- 
ally, however,  the  lateral  borders  of  the  prostate  presented  an  irregu- 
lar ridge.  Periprostatic  adhesions  and  bands  were  present  in  a  few 
cases,  in  some  instances  producing  septa  which  stood  out  prominently 
in  the  rectum. 


66  Hugh  H.  Young. 

In  the  vast  majority  of  cases,  however  (130  out  of  145),  the  sur- 
face of  the  prostate  was  smooth  and  the  general  contour  fairly  regular 
and  symmetrical  with  the  exception  of  an  occasional  greater  enlarge- 
ment of  one  of  the  lateral  lobes.  The  median  furrow  and  notch  were 
obliterated  in  many  cases,  but  in  others  they  were  wide  and  deep.  I 
could  make  out  very  little  relationship  between  the  character  and 
amount  of  obstruction  present  and  the  presence  or  absence  of  furrow 
or  notch.  It  is  generally  held  that  when  the  median  lobe  is  enlarged 
the  superior  notch  is  obliterated,  and  while  this  is  true  in  many  cases, 
and  particularly  those  of  large  median  lobes,  I  have  seen  a  number 
of  cases  with  little  or  no  median  enlargement  in  which  the  notch  and 
furrow  were  obliterated,  and  cases  of  median  enlargement  in  which 
the  notch  was  present. 

My  opinion  is  that  the  notch  and  furrow  are  dependent  upon  the 
direction  of  growth  of  the  lateral  lobes  and  whether  they  are  closely 
bound  together  by  the  capsule  or  not.  Where  the  capsule  is  lax  and 
thin  the  lateral  lobes  frequently  have  a  divergent  growth,  a  tendency 
to  grow  laterally,  and  upward  and  outward  into  the  region  of  the 
seminal  vesicles,  and  in  such  cases  we  frequently  find  wide  and  deep 
furrows  and  notches.  I  have  noticed  that  such  cases  are  frequently 
associated  with  very  little  rbstruction  to  urination  in  comparison  with 
the  size  of  the  prostate,  and  I  believe  it  is  because,  not  being  firmly 
held  together  by  the  capsule,  they  do  not  greatly  compress  the  urethra, 
and  urination  is  little  interfered  with. 

Consistence  of  prostate. — The  prostate  was  described  as  distinctly 
soft  in  56  cases;  elastic  in  26  cases;  firm  in  45  cases;  moderately  hard 
in  14  cases;  very  hard,  no  cases. 

The  seminal  vesicles  were  slightly  indurated  in  19  cases,  and  moder- 
ately indurated  in  five  cases,  in  the  remaining  cases  there  was  no 
induration  found. 

The  intervesicular  space  was  slightly  indurated  in  two  cases  and 
moderately  indurated  in  two  cases.  The  whole  base  of  the  bladder 
felt  hard  in  one  case. 

Grlands  were  palpable  in  the  pelvis  in  five  cases. 

As  shown  by  the  above  figures  the  soft  and  the  elastic  prostates  form 
by  far  the  greater  number,  in  fact  these  two  varieties  should  be  classed 
together,  as  there  is  only  a  slight  variation  between  them.  The  pros- 
tate in  such  cases  was  soft,  compressible,  generally  elastic  but  at  times 


study  of  145  Cases  of  'Perineal  Prostatectomy.  67 

boggy.  The  capsule  covering  it  was  apparently  very  thin  and  the 
consistence  was  usually  uniform,  though  small  areas  or  lobules  of  a 
firmer  consistence  were  sometimes  present. 

The  size  of  the  prostate  in  these  cases  was  generally  considerable, 
there  being  only  eight  out  of  the  40  cases  which  were  described  as 
slightly  enlarged  in  which  the  prostate  was  soft. 

The  45  cases  in  which  the  prostate  was  described  as  firm  comprise 
cases  in  which  there  was  no  induration  present  and  in  which  the 
prostate  was  elastic,  but  the  elasticity  was  of  moderate  degree  and 
evident  only  on  moderate  pressure.  The  consistence  in  these  cases 
was  usually  uniform  and  the  surface  smooth. 

In  the  14  cases  classed  as  moderately  hard  the  consistence  was  not 
elastic,  but  quite  firm,  although  not  of  stony  hardness.  In  these  cases 
there  was  usually  no  uniformit}^  in  consistence,  there  being  places 
of  greater  induration  than  others  and  often  slight  irregularity  of  sur- 
face, and  the  induration  was  generally  most  marked  at  the  upper 
end  along  the  region  of  the  ejaculatory  ducts  and  adjacent  to  the 
bases  of  the  seminal  vesicles. 

The  complete  absence  of  cases  of  stony  hardness  of  the  prostate  is 
interesting  as  showing  an  important  differentiation  between  benign  and 
carcinomatous  enlargement.  The  figures  in  regard  to  the  seminal 
vesicles  are  not  entirely  accurate  owing  to  the  fact  that  they  could 
not,  owing  to  the  size  of  the  prostate,  be  reached  with  the  finger  in 
many  cases,  but  among  the  90  cases  of  slight  and  moderate  enlarge- 
ment of  the  prostate  it  should  have  been  possible  in  nearly  all  cases 
to  appreciate  induration  in  the  region  of  the  seminal  vesicles  and  in 
the  intervesicular  space  had  it  been  present.  I  therefore  feel  safe  in 
asserting  that  in  the  great  majority  of  cases  of  enlarged  prostate,  the 
seminal  vesicles  are  negative. 

A  study  of  the  cases  in  which  the  prostate  was  described  as  moder- 
ately hard  shows  that  the  prostate  was  only  slightly  enlarged  in  most 
of  the  cases,  and  microscopic  examination  showed  a  condition  of 
chronic  prostatitis  or  fibro-muscular  hypertrophy.  In  five  cases  in 
which  a  single  hard  area,  usually  a  small  rounded  lobule  which  pro- 
jected beyond  the  limit  of  the  prostatic  capsule  at  the  upper  end  of  the 
prostate  on  one  side,  was  present,  the  prostate  was  more  or  less  con- 
siderably enlarged,  but  the  rest  of  the  prostate  in  each  of  these  cases 
was  described  as  smooth  and  elastic.  N'o  case  of  considerable  enlarge- 
ment of  the  prostate  with  marked  general  induration  is  present  in  this 


68  Hugh  H.  Young. 

series,  and  this  is  all  the  more  remarkable  because  there  are  many 
cases  of  considerable  prostatic  hypertrophy  in  which  the  microscope 
shows  marked  prostatitis.  There  is,  however,  usually  a  large  amount 
of  adenomatous  tissue  present,  and  the  softness  which  this  imparts 
has  apparently  been  sufficient  to  keep  the  prostate  from  feeling  hard. 

In  two  cases  small  smooth  isolated  lobules  with  marked  induration 
projected  from  the  anterior  portion  of  a  prostatic  lobe,  and  the  sections 
in  both  of  these  cases  showed  localized  prostatitis  in  these  portions. 

Two  cases  in  which  the  prostate  was  considerably  indurated  and 
irregular  were  found  at  operation  to  contain  numerus  seed  calculi, 
which  was  scattered  throughout  the  prostate,  but  were  particularly 
numerous  just  beneath  the  posterior  capsule.  In  both  of  these  cases 
the  induration  was  sufficient  to  make  us  suspect  carcinoma. 

A  review  of  the  24  cases  which  showed  more  or  less  induration  of  the 
seminal  vesicles  or  intravesicular  space  reveals  but  three  cases  of  more 
than  slight  enlargement  of  the  prostate.  In  the  majority  of  instances 
the  prostate  was  of  a  small  fibro-muscular  or  chronic  inflammatory 
type,  and  the  process  in  the  vesicles  was  evidently  similar  in  character. 
In  most  cases  it  was  shown  merely  as  a  slight  thickening  of  the  seminal 
vesicles.  In  four  cases  an  indurated  cord  or  two  was  present  in  the 
region  of  the  vesicle,  and  in  iive  cases  one  or  more  enlarged  glands 
could  be  felt  adjacent  to  the  seminal  vesicle  or  along  the  pelvic  wall 
a  little  further  out. 

The  great  rarity  of  palpable  or  enlarged  glands  in  the  pelvis  in 
these  cases  is  all  the  more  remarkable  when  we  consider  the  large 
number  of  cases  in  which  there  is  considerable  vesical  infection  and 
inflammation  which  has  extended  to  the  prostate  and  seminal  vesicles. 
This  observation  is  true  also  as  regards  cases  of  chronic  gonorrhoea! 
prostatitis  and  seminal  vesiculitis,  in  which  I  have  made  many  care- 
ful examinations  and  have  only  found  palpable  glands  in  very  rare 
instances.  The  fact,  too,  that  in  fatal  cases  of  carcinoma  of  the  pros- 
tate, enlarged  glands  have  been  found  at  autopsy  in  the  pelvis  in  only 
27  out  of  100  cases  would  seem  to  show,  along  with  the  findings  given 
above,  that  the  pelvic  glands  are  little  prone  to  involvement  either  in 
inflammatory  or  in  malignant  disease  of  the  prostate,  and  therefore 
their  presence  or  absence  is  apparently  of  very  little  diagnostic  value 
in  differentiating  benign  and  malignant  prostatic  enlargement. 

The  indurated  cords  which  have  been  mentioned  above  were  similar 
to  those  which  are  commonly  felt  in  chronic  inflammation  of  the 


study  of  IJfO  Cases  of  'Perineal  Prostateciomy.  69 

prostate  and  seminal  vesicles,  and  are  in  some  cases,  I  believe,  simply 
indurated  vasa  deferentia.  In  other  cases,  especially  wliere  multiple, 
they  are  certainly  indurated  lymphatics  "o-hich  accompany  the  seminal 
vesicle. 

In  view  of  the  importance  of  induration  in  the  region  of  the  prostate 
and  seminal  vesicles,  I  will  give  briefly  the  rectal  findings  in  four 
cases  which  were  afterwards  found  to  be  carcinomatous. 

Case  I. — No.  10,  carcinoma  series.  Frequency  and  difficulty  of  urination 
for  three  years;  no  pain  until  recently.  He  has  complete  retention  of  urine 
and  1500  cc.  is  withdrawn.  The  prostate  is  only  slightly  larger  than 
normal,  smooth,  uniformly  indurated  and  of  stony  hardness.  Both 
seminal  vesicles  are  slightly  indurated.  The  cystoscope  shows  no  intra- 
vesical lobe,  but  a  small  hypertrophied  collar  all  around  the  orifice.  "With 
finger  in  rectum  and  cystoscope  in  urethra  there  is  considerable  Increase 
in  the  median  portion.  At  operation  both  lobes  were  extremely  :tfbrous, 
closely  attached  to  the  capsule  and  had  to  be  excised  with  scissors  and 
scalpel.  The  tissue  removed  weighed  only  G-8,  and  microscopically  showed 
carcinoma. 

Case  II. — No.  11,  carcinoma  series.  Frequency  and  difficulty  of  urin- 
ation for  four  years.  Pain  in  bladder,  no  hematuria.  The  prostate  is 
moderately  enlarged,  round  and  smooth.  The  right  lobe  is  the  larger  and 
is  slightly  indurated,  but  is  slightly  hard,  but  the  induration  does  not 
extend  into  the  region  of  the  seminal  vesicles.  Several  indurated  cords 
run  upward  from  it  to  the  lateral  walls  of  the  pelvis.  The  left  lobe  is 
smaller,  softer  and  there  are  no  indurated  cords.  The  seminal  vesicles 
are  not  palpable,  there  is  no  intervesicular  mass  and  no  enlarged  glands. 
The  cystoscope  cannot  be  introduced  into  the  bladder.  At  operation  the 
prostate  was  not  difficult  to  separate  from  the  rectum  and  was  only  slightly 
indurated.  At  the  upper  end  the  right  lateral  lobe  was  adherent  and  had 
to  be  excised  with  scissors.  Examination  showed  an  area  deep  yellow 
in  color  and  hard  as  cartilage.  The  rest  of  the  hypertrophy  was  benign 
in  appearance.    Sections  from  the  suspicious  area  showed  adenocarcinoma. 

Case  III. — No.  9,  carcinoma  series.  Frequency  and  difficulty  of  urin- 
ation two  years.  Pain  in  the  urethra,  no  hematuria.  The  prostate  is 
considerably  enlarged,  smooth,  rather  hard  in  consistence,  the  median 
furrow  is  shallow,  but  the  notch  is  quite  deep.  The  seminal  vesicles  cannot 
be  palpated,  but  the  lateral  lobes  extend  upward  and  outward  into  the 
region  of  the  seminal  vesicles  and  are  quite  closely  adherent  to  the  pelvic 
walls.  The  cystoscope  shows  two  large  intravesical  lateral  lobes;  no 
median  lobe  present.  At  operation  the  lateral  lobes  were  surprisingly 
small  and  very  adherent.  Microscopic  examination  showed  benign  h3T)er- 
trophy  with  one  small  area  of  definite  malignancy. 


70  Hugh  H.  Young. 

Case  IV.  No.  12,  carcinoma  series.  Occasional  frequency  of  urination 
for  one  year.  Pain  during  urination  for  six  months.  The  prostate  is  very 
slightly  enlarged,  irregular  and  very  hard.  At  the  base  of  the  right  seminal 
vesicle  there  is  a  small  area  of  induration  1  cm.  in  size,  above  that  the 
seminal  vesicle  is  negative.  The  left  vesicle  is  negative.  The  membranous 
urethra  is  enlarged,  hard,  the  induration  being  continuous  with  that  of 
the  prostate  and  extending  to  the  bulb.  No  enlarged  glands  felt.  It  is 
impossible  to  pass  instruments  owing  to  tight  stricture  in  the  membranous 
urethra.  At  operation  the  prostatic  tissue  was  very  hard,  adherent  to  the 
capsule,  and  had  to  be  cut  away  with  scissors  especially  in  the  region  of 
the  base  of  the  right  vesicle.    The  microscope  showed  carcinoma. 

Benign  cases  suggesting  malignancy: 

I  (105).  Cystitis  and  frequency  of  urination  15  years  ago.  No  history 
of  complete  retention  of  urine.  Micturition  three  or  four  times  at  night 
and  twice  in  the  day.  No  hematuria  nor  pain.  The  prostate  is  moderately 
enlarged,  smooth,  firm  but  not  of  stony  hardness  and  slightly  elastic. 
There  is  induration  at  junction  of  prostate  and  seminal  vesicle  on  both 
sides,  and  several  firm  fibrous  cords  are  felt  extending  from  the  middle 
and  from  the  upper  end  of  the  prostate  to  the  pelvic  wall  on  both  sides. 
The  seminal  vesicles  are  not  markedly  indurated  and  there  is  no  inter- 
vesicular  mass.  The  outer  borders  of  the  seminal  vesicles  are  adherent 
to  the  lateral  structures  on  both  sides  and  several  enlarged  glands  are  felt 
in  the  left  side  next  to  the  pelvic  wall  and  also  in  the  sacral  fossa.  The 
cystoscope  shows  a  small  sessile  rounded  median  lobe.  There  is  no 
subtrigonal  thickening,  but  the  median  portion  of  the  prostate  is  enlarged 
and  quite  hard.  In  this  case  the  history  and  cystoscopic  findings  were 
against  cancer,  and  the  induration  of  the  prostate  was  not  typical,  but 
the  presence  of  indurated  lymphatics  and  enlarged  glands  made  one  suspect 
cancer.  At  operation  the  prostatic  tissue  was  firm  and  showed  small 
yellowish  dots  and  lines  resembling  cancer,  but  the  microscope  shows 
simply  a  chronic  prostatitis,  and  the  patient  is  well  now  one  year  after 
operation. 

II  (140).  Began  one  and  one-half  years  ago  with  burning  during  urin- 
ation, frequency  and  difficulty,  since  then  considerable  pain  and  hematuria. 
The  prostate  is  not  much  enlarged,  smooth,  moderately  indurated,  but 
not  of  stony  hardness.  The  right  seminal  vesicle  is  not  enlarged,  but 
several  hard  cords  are  felt  in  this  region  and  three  or  four  enlarged 
indurated  glands  are  present  at  the  outer  border  along  the  pelvic  wall. 
Cords  are  similarly  present  on  the  other  side,  and  in  the  sacral  fossa  there 
is  a  small  mass  suggesting  glands.  The  cystoscope  shows  a  large,  smooth, 
oval  calculus,  and  moderate  enlargement  of  the  median  portion  of  the 
prostate.  With  finger  in  rectum  and  cystoscope  in  urethra  there  is  no 
subtrigonal  thickening  and  only  a  moderate  enlargement  of  the  median 
portion  of  the  prostate.  At  operation  benign  hypertrophy  with  prostatitis 
was  demonstrated.    The  lobes  enucleated  easily. 


study  of  14-5  Cases  of  'Perineal  Prostatectomy.  71 

III  (131).  Frequency  of  urination  for  15  years.  Considerable  difficulty 
and  hematuria.  The  prostate  is  considerably  hypertrophied,  smooth,  firm, 
elastic,  no  areas  of  induration  and  no  tenderness  in  the  prostate.  Extend- 
ing upward  and  outward  from  the  upper  end  of  each  lateral  lobe  is  an  area 
of  induration  in  the  region  of  the  seminal  vesicle  which  is  particularly 
marked  on  the  right.  This  induration  is  not  of  stony  hardness,  but  is  quite 
firm  and  irregular.  No  enlarged  glands  are  present.  An  intervesicular 
plateau  of  moderate  induration  is  present.  The  cystoscope  shows  a  median 
lobe  of  considerable  size.  At  operation  a  typical  benign  prostate,  with 
considerable  prostatitis  present,  was  removed. 

The  Cystoscopic  Findings. 

The  cystoscope  was  employed  in  133  of  the  145  cases.  It  was  not 
used  in  the  12  cases  for  various  reasons :  in  four  because  the  operation 
was  done  away  from  home  and  cystoscopy  could  not  be  carried  out, 
in  three  cases  because  suprapubic  fistulse  were  present,  and  a  report 
was  made  as  to  the  condition  within  the  bladder,  and  in  the  other 
cases  because  the  patients  were  too  weak  to  be  disturbed.  In  two  cases 
cystoscopy  was  attempted  but  the  instrument  could  not  be  introduced 
into  the  bladder.  One  of  these  cases  had  false  passages  in  the  region 
of  the  membranous  urethra  which  prevented  catheterization,  and  the 
second  was  a  case  of  very  great  prostatic  hypertrophy  in  which  it  was 
impossible  to  get  the  cystoscope  over  the  median  enlargement.  In 
six  cases  cystoscopy  was  interfered  with  by  hemorrhage  so  much  as  to 
render  the  examination  unsatisfactory.  In  some  other  instances 
hemorrhage  occurred,  but  not  until  late  or  not  in  sufficient  amount  to 
interfere  with  the  examination. 

The  condition  of  the  intravesical  portion  of  the  prostate,  as  shown 
by  the  cystoscope  in  the  125  cases  in  which  satisfactory  examinations 
were  obtained,  were  as  follows : 

Median  lohe. — Slight  bar,  39;  small  round  lobe,  37;  moderate  en- 
largement, 27;  considerable  enlargement,  14;  great  enlargement,  two; 
huge  enlargement,  one. 

Right  lateral. — Not  intravesically  enlarged,  11;  slight  enlargement, 
55;  moderate  enlargement,  28;  consderable  enlargement,  17;  great  en- 
largement, two;  huge,  one. 

Left  lohe. — ISTo  intravesical  enlargement,  13;  slight,  52;  moderate, 
25;  considerable,  19;  great,  two;  huge,  one. 

Anterior  lohe. — Five  cases. 

Circular  collar  around  the  entire  orifice,  one  case. 


72  Hugh  H.  Young. 

Intraurethrally  projecting  lohes. — Four  cases. 

Vesical  calculi  present. — Twenty-five  cases. 

Vesical  diverticula  present. — Seventeen  cases. 

Pouches  and  cellules. — IsTumerons  cases. 

In  another  portion  of  this  volume  so  much  space  is  devoted  to  the 
importance  of  the  cystoscope  as  a  diagnostic  aid  in  diseases  of  the 
prostate  that  it  will  be  out  of  place  to  discuss  the  question  in  detail 
here.  The  cystoscopic  chart  (elsewhere  described)  has  been  used  in 
almost  all  of  the  cases  and  has  proved  invaluable  in  the  interpretation 
of  the  many  and  peculiar  forms  of  intravesical  outgrowths  of  the 
prostatic  lobes,  and  without  its  use  I  feel  absolutely  certain  that  it 
would  have  been  impossible  for  me  to  interpret  the  findings  in  many 
cases.  This  is  particularly  true  in  the  case  of  median  lobes  in  which 
the  cystoscope  may  lie  either  on  top  or  in  the  sulcus  to  the  right  or  the 
sulcus  to  the  left  of  the  median  lobe,  and  in  each  position  an  entirely 
different  and  apparently  contradictory  set  of  pictures  will  be  obtained 
unless  elucidated  by  the  method  of  charting  spoken  of  above. 

In  regard  to  the  findings  tabulated  above  one  is  struck  with  the  fairly 
large  number  of  cases  in  which  there  is  no  intravesical  enlargement  of 
the  lateral  lobes  shown.  It  not  infrequently  happens,  especially  if 
there  is  a  small  median  lobe  present  to  lift  up  the  prostatic  orifice,  that 
the  lateral  lobes  do  not  grow  towards  the  bladder,  but  push  upward 
into  the  region  of  the  seminal  vesicles  so  that  on  cystoscopic  examina- 
tion no  intravesical  enlargement  of  the  lateral  lobes  is  seen,  although 
there  may  be  a  considerable  enlargement  of  the  lateral  lobes  found  on 
rectal  examination. 

Another  interesting  finding  has  been  that  when  one  lateral  lobe 
presented  more  prominently  to  the  examining  finger  in  the  rectum  the 
other  lateral  lobe  would  be  found  to  present  more  prominently  into 
the  bladder  with  the  cystoscope.  This  has  been  noted  in  a  great  many 
cases,  and  it  seems  evident  that  in  the  constricted  space  in  which  these 
enlargements  are  produced,  occasionally  one  will  be  crowded  posteriorly 
and  the  other  anteriorly. 

Median  lohes. — One  is  also  struck  with  the  number  of  cases  in  which 
the  median  enlargement  is  only  slight  in  degree.  As  noted  above,  in 
37  cases  the  median  enlargement  was  in  the  shape  of  a  small  globular, 
sessile  or  pedunculated  median  lobe.  In  many  of  these  cases  it  was 
not  more  than  1  or  S  cm.  in  diameter,  and  yet  the  obstruction  was 
often  just  as  great  as  in  some  of  the  very  great  hypertrophies.     In 


study  of  lJf.0  Cases  of  ■Perineal  Prostatectomy.  73 

39  cases  the  median  enlargement  was  in  the  shape  of  a  small  trans- 
verse bar  and  on  cystoscopic  examination  the  instrument  shoTs^ed  no 
sulci  on  either  side,  and  it  was  impossible  to  get  the  triple  set  of  pic- 
tures which  can  usually  be  obtained  when  the  lobe  is  globular  in 
shape  with  a  deep  sulcus  on  each  side.  In  most  cases  this  median 
bar  was  a  distinct  hypertrophy  or  thickening  of  the  median  portion 
of  the  prostate,  but  in  a  few  cases  it  was  a  mere  septum-like  membrane 
which  joined  intravesically  enlarged  lateral  lobes,  and  was  apparently 
an  artefact  or  fold  of  mucous  membrane  produced  by  the  upward 
growth  of  the  intravesically  enlarging  lateral  lobes.  In  such  cases  it 
was  often  completely  hidden  behind  the  approximated  lateral  lobes, 
but  on  elevating  the  handle  of  the  cystoscope  so  as  to  separate  the 
lower  portions  of  the  lateral  lobes  the  median  fold  was  brought  into 
view  (cases  120,  5). 

In  12  cases  the  middle  lobe  was  considerable  in  size,  in  two  cases 
great,  and  in  one  case  huge.  In  the  latter  case  the  intravesical  mass, 
which  was  composed  of  median  and  lateral  lobes  fused  together,  was 
about  the  size  of  a  cocoanut,  and  completely  filled  the  bladder  (which 
was  large).  In  two  cases  middle  lobes  the  size  of  an  orange  were 
present,  and  in  12  cases  from  the  size  of  a  hen^s  egg  to  that  of  a 
lemon.  In  some  instances  these  lobes  were  directed  anteriorly,  but  in 
others  they  lay  upon  the  floor  of  the  bladder  completely  covering  the 
trigone  and  in  some  cases  much  of  the  base  of  the  bladder. 

Tlie  lateral  lohes. — As  seen  in  the  tabulation  above,  the  right  and 
left  lateral  lobes  were  about  equally  subjects  of  intravesical  enlarge- 
ment. As  remarked  above,  in  about  a  dozen  cases  there  was  appar- 
ently no  enlargement  towards  the  bladder  of  the  lateral  lobes,  and  this 
was  so,  not  only  in  some  cases  in  which  the  lateral  lobes  were  small, 
but  also  in  a  few  cases  in  which  the  lateral  lobes  were  fairly  large. 
In  these  cases  the  lateral  lobes  had  grown  laterally  or  posteriorly 
rather  than  intravesically.  In  one  remarkable  case,  however  (126), 
in  which  rectal  examination  showed  the  prostate  very  little  larger 
than  normal,  and  cystoscopic  examination  showed  no  intravesical  en- 
largement of  the  lateral  lobes  (and  also  very  little  of  the  median),  I 
was  surprised  to  find  at  operation  that  the  lateral  lobes  were  quite 
large,  but  that  their  growth  had  been  directed  toward  the  s}Tnphysis 
pubis,  so  that  they  presented  practically  no  enlargement  posteriorly 
or  intravesically.  In  this  case  the  posterior  capsule  of  the  prostate 
was  extremely  thick  and  dense,  and  the  vesical  neck  was  also  very 
Vol.  XIV.— 6. 


74  •;.  Hugh  H.  Young. 

thick  and  firm,  and  admitted  the  index  finger  only  after  considerable 
pressure  was  made.  I  have  no  donbt  that  the  firmness  of  the  prostatic 
capsule  in  these  two  directions  was  responsible  for  the  peculiar  anterior 
growth  of  the  lateral  lobes  described  above,  I  have  never  seen  this 
condition  in  any  other  case  or  any  reference  to  it  in  the  literature. 

Anterior  lohe. — In  five  cases  a  fairly  considerable  lobule  was  seen 
anterior  to  the  urethral  orifice,  and  so  separated  from  the  lateral  lobes 
that  it  really  presented  as  an  anterior  lobe  overhanging  the  urethral 
orifice  (50,  6,  120,  104,  65).  The  cystoscope,  however,  showed  that 
the  sulcus  separating  it  from  one  of  the  lateral  lobes  was  much  deeper 
than  that  separating  it  from  the  other,  and  at  operation  a  definite 
connection  with  one  of  the  lateral  lobes  was  determined  in  two  cases, 
and  the  lobe  was  easily  removed  along  with  or  after  the  lateral  lobe 
through  the  lateral  cavity.  It  cannot,  therefore,  be  said  that  any  of 
these  cases  presented  a  definite  anterior  lobe  which  was  connected  in 
no  way  with  the  lateral  lobes  and  was  entirely  separate  in  its  growth. 
I  have  seen  one  such  case  in  the  Museum  of  the  Eoyal  College  of 
Surgeons,  London,  the  enlargement  being  entirely  of  the  anterior 
commisure  of  the  prostate. 

In  one  case  (53)  the  anterior  portion  of  the  prostatic  margin  formed 
part  of  a  definite  collarette  around  the  prostatic  orifice  and  was  un- 
doubtedly definitely  thickened,  and  in  several  cases  in  which  the  lateral 
lobes  had  grown  out  quite  far  into  the  bladder,  I  have  seen  the  an- 
terior margin  of  the  prostate  appear  as  a  septum-like  fold  as  happens 
also  in  the  median  portion  posteriorly  in  certain  similar  cases,  but  a 
study  of  these  cases  shows  conclusively  that  it  is  very  rare  indeed  for 
the  anterior  portion  of  the  prostate  to  furnish  any  obstructing  enlarge- 
ment, and,  therefore,  that  the  anteriorly  directed  incision  which  has 
been  generally  employed  in  the  Bottini  operation  has  had  no  patho- 
logical justification. 

Intraurethral  enlargements. — In  two  cases  I  discovered  definite 
lobules  projecting  intraurethrally.  One  of  these  cases  (82)  has  been 
described  in  full  in  the  article  on  the  use  of  the  cystoscope  in  diseases 
of  the  prostate,  case  21.  The  other  case  is  given  briefly  elsewhere 
(case  119).  In  both  of  these  cases  when  the  cystoscopic  prism  was 
drawn  outward  beyond  the  vesical  sphincter,  lateral  enlargements 
projecting  toward  the  urethra  were  seen,  and  undoubtedly  furnished 
considerable  obstruction  to  the  outflow  of  the  urine. 


study  of  llf.5  Cases  of  'Perineal  Prostatectomy.  75 

It  seems  probable,  however,  that  had  it  been  possible  to  cystoscope 
the  posterior  urethra,  as  was  done  in  these  two  cases,  we  would  have 
found  intraurethrally  projecting  lobules  in  a  number  of  cases. 

Vesical  diverticula. — The  cystoscope  was  not  only  of  very  great 
value  in  mapping  out  the  character  and  size  of  the  various  prostatic 
outgrowths,  but  also  in  determining  the  condition  of  the  bladder.  In 
practically  all  cases  more  or  less  trabeculation  of  the  bladder  was 
found.  In  cases  where  the  obstruction  was  apparently  of  recent  origin 
the  trabeculation  was  often  not  very  great  and  was  usually  associated 
with  a  contracture  of  the  bladder.  In  the  older  cases  the  hyper- 
trophied  muscle  bundles  were  more  prominent  and  there  was  more 
or  less  extensive  pouch  formation  between  them.  In  a  number  of 
cases,  where  the  pressure  had  been  considerable,  the  orifices  of  small 
intramuscular  cellules  were  seen,  particularly  on  the  posterior  and 
posterolateral  aspects  of  the  bladder.  In  18  cases  the  presence  of  defi- 
nite extravesical  diverticula  was  made  out.  These  occurred  usually 
just  external  to  one  of  the  urethral  orifices.  Occasionally  they  were 
found  in  the  vertex  of  the  bladder  in  the  region  of  the  beginning  of 
the  urachus,  and  these  three  positions  furnished  by  far  the  most  com- 
mon sites  for  their  occurrence.  Not  infrequently  diverticula  were 
seen  in  all  three  locations.  As  remarked  in  the  article  on  this  subject 
in  Vol.  XIII  of  these  reports,  diverticula  occurring  in  the  region  of 
the  ureteral  orifices  are  capable,  not  only  of  pressing  upon  the 
ureters  and  thereby  obstructing  the  flow  of  urine,  but  also  draw- 
ing the  ureteral  orifice  into  their  cavities  in  their  progressive  en- 
largement. Such  was  the  case  in  two  of  these  cases,  and  it  was  on 
account  of  the  fear  of  subsequent  injury  to  the  kidney  and  ureter,  on 
that  side,  that  I  advised  removal  of  the  prostatic  obstruction  in  one 
of  these  cases  (143).  In  one  case  (30)  a  very  large  diverticulum  was 
present  and  communicated  with  the  bladder  by  a  small  orifice  on  the 
anterior  wall  slightly  to  the  right  of  the  median  line.  In  this  case  it 
was  possible  to  introduce  the  cystoscope  through  the  orifice  and  care- 
fully examine  the  interior  of  the  diverticulum  which  was  found  to 
extend  far  backward  along  the  lateral  walls  of  the  bladder  and  rectum 
as  far  as  the  sacrum.  On  account  of  the  fear  of  serious  complications 
which  might  follow  infection  of  this  large  extravesical  pouch  I  advised 
and  carried  out  excision  of  the  diverticulum  suprapubically  pre- 
liminary to  perineal  prostatectomy.  This  was  the  only  case  in  which 
a  very  large  diverticulum  communicated  with  the  bladder  on  the 


76  Hm^k  H.  Tmtm^. 

anterior  wall  m^  ssadi  &  sjmgM  fmBie&.  and  in.  tbe  oilier  ca^s 
Hie  direirticsiilla  irere  m.  sradh  positiom  or  of  msA  size  ItUt  I  did  mot 
fear  tibe  idtenUoii  of  septic  prodmcls  -witMm  itiirar  cawi&s,  and  was 
contait  to  mnqply  nanore  iSie  olieir"i :iiii.z  iris'  "-  " t :: gtimg  tlnat;  Hiie 
dinrerticinila  ■wouild  imoie  or  Itejas  ©DiriT.e'rlj  :•:_!'£-  ~.  ia.  aM  impedi- 
ment  to  free  -mdoaalioii  was  iiranc'ri.  Tiis  Isope  lias  lie@a  xeaMsed 
in  pKadticaIfy  aQ  of  liiese  cases,  sotatify  mm  i^}i  in  iK^iidi  Mwb  fms^ 
lai^  divt'ei'liciiLBa  m^e  presomL 

De^  intrawe^cal  poiudiies  willi  proatniiiiiatit  septa  of  mimcoiiiffi  wmn^ 
bjame aii; .1  I't" T  ~-:'t  ^r-fz  :~  fr"-:.-.  ';--^  ~ airtticnilffirly oni ft© posttEsoor 
waini  of  '-  '  -■  -  -'■--.  :'::  :~±r:::rL:.-  • -■eiii  poiiiiA  was  pisfflsnt  Ibe- 
Thiiinid  a  ni;::  j."— 'rrTr itI/.t :  izi  -::n..::z*  /rMmCTitnm  iMiksnuiffidEr- 
ienm,  ani  iz.  :~t  -;  _  ..i"r  srrz.  "It  .17:^1  ;:m  i  ~riy  pOTiminciilt 
tiaiBSweirsT  -r :";:;:.  ""'„::.:.  i:"^-"T7  :it  :..iiir7  Tri~i"Tr=4ely  into  an 
antamor  An-  "-Tt::::  T'::?::::  11.:  ::r:_iTi  2,  zii.r^ri  :  ::-?rrBetioii  to 
uranatio:!..  Zi:  in  '.i~  zii;::LT7'  ::  :L;"::,~:r;  ^TTti.  "■:":ir:;.  iri 
diveriaciii-j,  ri"^  "^^17  _~-r  T::"i.:-r  i^i:.:  i:ir  i:  ji'^in:  iZ_L3g£i:ii^:  :ii-5 
been  rerr  :~fc 


m  one  c:i^ 
eoliis,  istt: 
iniBieiri; 
Ihey  iper-r 
cnlns  oir  :: 
stances  r:: 
mmllniirwCTi'- , 
In  iffiir-r 
and  ^i&  ': 
nsmatunni 
IsfflmoncLj;  r 

fedtOEJ  ~-'. 

cowered. 
tBcted.    A 

a   SEEfflELr"  ' 

letusneii  '~ 
liave  cc-r. 


bladder 
tnd^BE 


study  of  IJ+o  Cases  of  'Perineal  Prostatectomy.  77 

In  a  number  of  these  cases  the  knowledge  that  a  calculus  "was  present 
was  of  very  great  value  during  the  operation  for  only  by  persistent 
searching  -with  forceps  and  spoons  were  the  calculi  secured. 

The  advantage  of  cystoscopy  in  all  cases  of  prostatic  hypertrophy 
before 'operation  is  therefore  very  great  as  demonstrated  in  the  cases 
mentioned  above.  Xot  only  is  the  operator  forewarned  as  to  the 
presence  of  calculi  or  diverticula  or  intravesical  tumors,  but  the  accu- 
rate knowledge  obtained  as  to  the  location,  character,  and  size  of  the 
prostatic  enlargements  enables  him  to  operate  with  a  confidence  of 
removing  all  the  obstructing  portions  and  with  the  least  loss  of  time 
and  mutilation  of  unobstructing  parts.  I  cannot  too  severely  con- 
demn the  obstinate  refusal  of  certain  operators  to  make  use  of  this 
valuable  and  enlightened  addition  to  our  diagnostic  measures. 

C.    PEELIMIXAET  TEEATMEXT. 

In  more  than  half  of  the  145  cases  here  reported  the  operation  was 
done  within  three  or  four  days  of  the  examination  of  the  patient  after 
admission.  In  a  few  public  ward  cases  the  operation  was  delayed 
owing  to  the  press  of  other  work,  and  in  several  private  cases  the 
operation  was  deferred  either  to  suit  the  convenience  of  the  operator 
or  the  patient,  but  in  only  41  cases  was  definite  preliminary  treatment 
thought  to  be  advisable.  It  was  carried  out  in  these  41  cases  for  the 
following  length  of  time : 

4  days   5   Cases. 


5 

6 

7 

8 

10 

11 

12 

13 


between  2  and  4  weeks 4 

3     "     4      "      4 

1  montli    4 

2  " 1 

4       "          1 

6  "          1 

7  "         1 


In  five  cases  the  patients  were  very  weak  old  men,  aged  77  (125),. 
78  (20),  76  (54),  81  (23),  82  (49).     Tour  of  these  case's  were  treated 


78  Eugh  H.  Young. 

by  continuous  drainage  with  the  catheter,  four,  eight,  eight,  and  24 
days  respectively.  The  fifth  case,  aged  81,  was  catheterized  twice 
daily  for  four  days  and  then  aspirated  twice  daily  for  six  days.  In 
this  case  the  bladder  was  greatly  dilated,  holding  over  2000  cc,  and 
this  was  the  only  case  in  which  the  operation  was  not  successful.  This 
patient  died  30  days  after  the  operation.  The  bladder  did  not  regain 
its  tone. 

In  10  cases  (20,  44,  118,  77,  136,  50,  107,  138,  23,  126)  the  pa- 
tients had  never  been  catheterized  and  there  was  a  very  large  amount 
of  residual  urine  present,  in  six  cases  being  between  500  and  1000  cc. 
and  in  four  cases  between  1000  and  2000  cc.  Eight  of  these  cases 
were  treated  by  catheterization  from  two  to  four  times  daily  for 
periods  varying  from  one  to  three  weeks.  One  case  was  treated  by 
continuous  drainage  through  a  catheter  for  eight  days  and  one  by 
intermittent  catheterization  followed  by  suprapubic  aspiration  for  six 
days.  In  all,  nine  cases  were  treated  by  continuous  drainage  through 
a  catheter  retained  in  the  urethra,  and  the  remainder,  with  exception 
of  one  case  of  suprapubic  drainage  for  seven  months,  were  treated 
by  intermittent  catheterization,  generally  three  times  daily,  occasion- 
ally only  twice  daily,  and  in  three  cases  from  four  to  six  times  daily. 
In  five  cases  (53,  37,  89,  82,  58)  strictures  of  the  urethra  were  present, 
and  dilatations  were  given  for  protracted  periods  varying  from  three 
weeks  to  several  months.  In  one  case  (38)  the  operation  was  delayed 
eight  days  on  account  of  epididymitis,  which  was  treated  by  ice  bags. 
In  two  cases  (52,  109)  marked  symptoms  of  renal  infection  were 
present  (nausea,  vomiting,  fever,  etc.),  and  in  one  continuous  cathet- 
erization was  maintained  for  10  days;  in  the  other  intermittent 
catheterization  for  four  days.  In  neither  instance  was  there  any  im- 
provement in  the  uremia  and  it  was  thought  best  to  supply  perineal 
drainage  at  operation.  Both  of  these  patients  died,  14  and  27  days 
respectively  after  the  operation,  of  pyonephrosis  and  uremia.  In 
one  case  (18)  continuous  drainage  through  a  retained  catheter  was 
maintained  for  10  days  on  account  of  severe  urethral  hemorrhages.  In 
two  cases  (72,  85)  the  operation  was  delayed  10  and  18  days  respect- 
ively on  account  of  pleurisy.  Two  cases  (51,  8)  were  treated  for  two 
and  four  months  respectively  on  account  of  contracture  of  the  bladder 
associated  with  chronic  obstructive  prostatitis  with  small  median  lobe 
enlargement,  by  urethral  dilatations  and  attempts  to  dilate  the  bladder 
by  hydraulic  pressure,  but  without  success.     One  case  (75)  had  sugar 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  79 

in  the  urine  and  was  put  upon  antidiabetic  diet  for  six  days.  During 
this  time  bicarbonate  of  soda  and  urotropin,  water,  catheterization, 
three  or  four  times  daily  were  employed.  Eight  cases  (6,  1,  124,  117, 
91,  132,  60,  74)  were  treated  by  intermittent  catheterization  for 
periods  varying  from  four  to  27  days.  All  of  these  patients  were 
weak  subjects,  and  four  at  least  showed  evidence  of  renal  insufficiency. 
One  had  had  hemiphlegia.  All  of  these  patients  recovered  and  were 
cured  by  operation.  One  case  (84),  with  a  small  sclerotic  inflamma- 
tory, prostate,  250  cc.  residual  urine  and  contracted  bladder,  was 
given  local  treatment  as  an  experiment,  viz.,  catheterization  twice 
daily,  irrigations,  urotropin,  and  urethral  dilatations  for  12  days, 
but  without  benefit  and  operation  was  therefore  decided  upon.  One 
case  (67)  had  a  considerably  distended  bladder,  urine  of  very  low 
specific  gravity  containing  very  little  urea,  nausea,  and  other  symp- 
toms of  uremia.  He  was  treated  by  catheterization,  at  times  continu- 
ous and  at  other  times  intermittent  for  43  days,  and  during  this  time 
the  specific  gravity  of  the  urine  improved  steadily  until  it  finally 
reached  1015  and  operation  was  followed  by  perfect  success. 

In  the  41  cases  given  in  more  or  less  detail  above,  the  patient  has 
nearly  always  received  urotropin  from  15  to  30  grains  daily  and 
water  in  abundance  by  mouth  and  sometimes  by  infusion  or  by  ene- 
mata.     In  very  few  instances  has  liquid  diet  been  employed. 

During  the  past  year  the  number  of  patients  receiving  preliminary 
treatment  for  three  or  four  days  has  been  considerably  less  than 
formerly,  and  the  operator  has  become  more  and  more  impressed  with 
the  fact  that  it  is  not  necessary  in  the  great  majority  of  cases.  Where 
the  patient  is  using  a  catheter  regularly  two  or  three  times  a  day, 
the  kidneys  are  in  fair  shape  and  the  general  health  good,  it 
seems  entirely  unnecessary  to  delay  operation  for  any  length  of  time. 
In  cases  with  calculus  present  the  sooner  the  operation  can  be  per- 
formed the  better  it  is  generally  for  the  patient.  In  patients  who 
have  never  used  a  catheter,  in  good  general  health,  with  urine  of 
fairly  good  specific  gravity,  with  no  definite  evidence  of  more  than 
slight  change  in  the  kidneys,  and  a  residual  urine  less  than  500  cc. 
only  a  few  catheterizations  are  necessary  as  a  rule  before  the  operation. 
As  soon  as  it  has  been  demonstrated  that  anuria  does  not  result  in  a 
given  case  after  drawing  off  the  urine,  it  is  generally  better  to  operate 
soon  rather  than  expose  the  bladder  to  almost  certain  infection,  when 
catheterization  for  a  protracted  period  is  carried  out. 


80  HugJi  H.  Young. 

In  patients  with  very  large  residual  urine,  who  have  never  been 
catheterized  previously  and  the  urine  sterile,  we  must  decide  between 
continuous  drainage  of  the  bladder  through  a  retained  catheter,  and 
frequent  catheterization  for  a  protracted  period  (with  the  ever-present 
danger  of  vesical  infection),  and  operation  after  only  a  few  days 
catheterization,  before  infection  of  the  bladder  occurs.  These  cases 
are  undoubtedly  among  the  most  dangerous  with  which  we  have  to 
deal  owing  to  the  fact  that  the  ureters  and  renal  pelves  are  almost 
always  greatly  dilated,  and  the  renal  cortex  correspondingly  atrophied. 

A  study  of  these  eases  would  seem  to  show  that  catheterization  three 
times  a  day  for  a  period  of  a  week  is  generally  sufficient  to  provide 
against  sudden  anuria,  to  cause  a  certain  amount  of  contraction  of  the 
dilated  ureters  and  renal  pelves,  and  sufficient  improvement  in  the 
urine  to  render  operation  safe,  and  if  urotropin  and  water  in  abun- 
dance be  taken,  and  great  care  observed  in  catheterization,  the  bladder 
can  generally  be  kept  free  from  infection.  The  best  catheter  to  use 
is  as  a  rule  a  French  gum  coude  catheter  of  medium  size  (16  to  18  F.) 
the  Forges  make  which  can  be  sterilized  by  boiling  before  being  used. 
Strict  precautions,  such  as  thoroughly  cleansing  the  glans  penis 
and  the  anterior  urethra  (by  irrigation),  and  by  irrigation  of  the 
bladder  with  boric  acid  solution  after  evacuation  of  the  urine,  should 
be  taken. 

In  cases  where  marked  evidence  of  poor  kidney  function,  as  in  the 
case  mentioned  above  (67),  is  present,  it  may  be  advisable  to  supply 
catheterization  for  a  protracted  period,  and  it  is  remarkable  how  great 
improvement  in  the  character  of  urine  will  result. 

In  cases  where  the  patient  is  uremic  and  definite  evidence  of  severe 
renal  infection  is  present,  frequent  catheterization  or  constant  drain- 
age along  with  hydrotherapy  and  urotropin  should  be  tried.  In  several 
instances  this  has  been  entirely  sufficient  to  relieve  the  renal  infection 
and  restore  the  patient  to  a  sufficiently  good  condition  for  prostatectomy 
though  in  one  of  my  cases  (No.  2,  carcinoma  series)  it  was  necessary 
to  maintain  continuous  drainage  for  five  weeks.  Where  the  patient 
does  not  improve  under  this  treatment  it  is  difficult  to  say  what 
is  the  best  procedure  to  adopt.  In  two  cases  (52,  109)  in  which  I  per- 
formed perineal  prostatectomy  in  order  to  supply  better  drainage,  the 
patients  finally  succumbed  to  their  kidney  disease.  Perhaps  simple 
suprapubic  drainage  will  prove  preferable,  but  in  my  two  cases  the 
patients  died  14  and  27  daj's  after  the  operation,  and  not  as  a  result 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  81 

of  it,  and  it  is  -difficiLlt  to  see  how  suprapubic  cystotomy  could  have 
supplied  better  drainage.  As  long  as  certain  physicians  allow  their 
patients  to  get  into  this  desperate  position  just  so  long  will  there 
remain  a  certain  number  of  cases  with  renal  lesions  too  severe  to  admit 
of  a  cure  of  the  patient  by  any  means. 

In  conclusion  I  may  say  that  prolonged  preliminary  treatment 
should  rarely  be  necessary.  Urotropin  should  usually  be  administered 
at  once  before  cystoscopy  is  performed  and  continued  through  the 
convalescence  after  operation,  but  care  should  be  taken  not  to  produce 
stomachic  irritation  by  it.  Where  the  catheter  has  not  been  used 
and  the  amount  of  residual  urine  present  is  not  very  great  (400  cc. 
or  less),  and  the  physical  and  urinary  examination  show  no  evidence 
of  marked  organic  lesions,  and  in  cases  where  regular  catheterization 
is  being  performed  several  times  daily,  it  is  not  necessary  to  wait  for 
a  protracted  period  before  performing  the  operation.  Where  definite 
evidences  of  organic  diseases  are  present,  and  where  a  very  large 
amount  of  residual  urine  is  present,  in  cases  which  have  never  been 
catheterized,  a  certain  amount  of  preliminary  treatment  will  be 
advisable  as  indicated  above,  but  as  a  rule  need  not  be  protracted  to 
any  great  length.  Intermittent  catheterization  is  in  a  way  better  than 
continuous  drainage  in  that  the  bladder  does  not  become  contracted, 
but  in  cases  with  severe  renal  lesions  continuous  catheter  drainage  is 
generally  more  eflScacious,  and  if  the  catheter  be  kept  closed  by  means 
of  a  clamp  which  is  removed  at  stated  intervals  to  allow  the  escape 
of  urine,  vesical  contracture  can  be  prevented.  The  objection  to 
continuous  catheter  drainage  is  the  considerable  urethral  and  vesical 
irritation  which  is  often  excited. 

D.    THE   OPERATIOIsr. 

Character  of  Teclmique. 
The  operation  performed  in  145  cases  was  in  most  all  of  the  cases 
exactly  in  accordance  to  the  technique  described  in  another  portion 
of  this  paper.  Among  the  early  cases,  when  the  operation  was  in  its 
developmental  stage  there  were  slight  differences,  e.  g.,  in  the  first 
case  a  transverse  capsular  incision  was  used;  in  the  second  case, 
after  stripping  back  the  posterior  capsule  the  urethra  was  opened  in 
the  median  line  posteriorly.  In  the  fourth  case,  however,  the  im- 
portance of  preserving  the  ejaculatory  ducts  was  recognized  and  since 
then  the  bilateral  capsular  incisions  with  preservation  of  the  sub- 
urethral tissues  immediately  surrounding  the  ejaculatory  ducts  has 


83  EugJi  H.  Young. 

invariably  been  employed  ,except  in  six  cases.  Four  of  these  patients 
had  lost  their  sexual  powers,  and  two  had  been  castrated,  and  the  sub- 
urethral method  of  removing  the  median  portion  was  employed. 

The  median  skin  incision  was  used  only  in  one  case  and  was  found 
to  be  so  inferior  as  regards  the  exposure  afforded  that  since  then  the 
inverted  V  incision  had  been  used.  The  fact  that  with  the 
latter  incision  all  of  the  operation  is  by  blunt  dissection  except  in  the 
median  line  and  exactly  the  same  as  would  be  employed  with  the 
median  skin  incision  has  convinced  me  that  it  is  foolish  to  attempt 
to  do  the  operation  through  a  median  incision,  when  with  the  inverted 
V-incision  no  more  deep  structures  axe  divided  and.  an  infinitely  better 
exposure  afforded. 

In  one  case  a  preliminary  incision  was  made  in  the  bulbous  urethra 
and  through  this  the  tractor  was  introduced  into  the  bladder.  This 
was  done  with  the  idea  of  leaving  the  posterior  urethra  entirely  intact, 
but  a  great  objection  was  found  to  this  method  in  that  the  prostate 
was  drawn  by  the  tractor,  not  toward  the  field  of  operation,  but 
toward  the  triangular  ligament,  so  that  the  exposure  afforded  was 
much  less  satisfactory  and  nothing  like  the  same  facility  of  making 
one  particular  portion  of  the  prostate  present  for  enucleation  was 
obtainable. 

It  is  evident  that  with  a  tractor  inserted  through  the  meatus  the 
same  objections,  but  still  greater  in  character,  would  occur.  Very 
early  in  the  development  of  this  operation  I  had  a  tractor  made  of 
extra  length  with  the  idea  of  introducing  it  through  the  meatus  and 
thus  avoiding  any  incision  into  the  urethra,  but  I  soon  found  that 
with  this  instrument  the  prostate  would  be  drawn  toward  the  symphy- 
sis pubis  and  away  from  the  field  of  operation.  The  dependent 
drainage  afforded  by  the  urethrotomy  in  the  membranous  urethra  is 
of  very  great  value  after  the  operation,  particularly  in  those  cases  in 
which  the  bladder  is  badly  infected  and  in  which  the  freest  possible 
escape  for  the  urine  is  desirable  owing  to  impaired  kidneys.  Another 
reason  for  the  perineal  drainage  tube  is  that  ocasionally  a  tear  is 
made  in  the  urethra  and  hemorrhage  from  the  prostatic  cavity  escapes 
into  the  bladder,  and  unless  continuous  irrigation  is  afforded  the 
tubes  (or  the  urethra  if  not  tube  drainage  is  furnished)  may  become 
plugged  with  blood.  I  therefore  consider  the  opening  in  the  mem- 
branous urethra  the  best,  not  only  on  account  of  the  excellent  traction 
afforded,  but  the  great  value  for  subsequent  drainage. 


study  of  lJj.5  Cases  of  'Perineal  Prostatectomy.  83 

In  four  cases,  owing  to  the  absence  of  infection,  no  tube  drainage 
for  the  bladder  was  furnished.  In  two  cases  the  result  was  ideal  in 
that  the  patient  voided  almost  immediately  tlirough  the  urethra 
the  bladder  did  not  become  infected,  and  the  perineal  fistula  closed 
in  six  days.  In  the  other  two  cases  the  urethra  became  plugged  with 
blood  and  catheterization  had  to  be  employed,  much  to  the  discomfort 
of  the  patient  and  entirely  vitiating  the  object  of  this  method.  I 
now  invariably  employ  double  tube  vesical  drainage  through  the  in- 
cision in  the  membranous  urethra.  Continuous  irrigation  from  a 
large  tank  of  sterile  salt  solution  is  maintained  until  the  morning 
after  the  operation.  In  cases  where  fairly  abundant  hemorrhage 
into  the  bladder  occurs  after  the  operation,  it  is  necessary  to  have 
fairly  free  irrigation  until  the  hemorrhage  stops  and  all  danger 
of  plugging  of  the  tubes  with  a  clot  of  blood  is  passed.  In  most 
cases,  however,  after  the  first  hour  or  two  it  is  possible  to  clamp  off 
most  of  the  lumen  of  the  tube  leading  from  the  tank  so  that  it  is  very 
little  trouble  for  the  nurse  to  add  warm  salt  solution  from  time  to 
time  sufficient  to  keep  the  irrigation  going.  In  cases  where  the  blad- 
der is  not  infected  great  care  has  been  taken  to  prevent  infection,  all 
tubes  and  solutions  used  being  carefully  sterilized,  the  exit  tube  ending 
in  a  bottle  which  contains  a  solution  of  bichloride  of  mercury,  to 
prevent  ascending  infection  from  this  receptacle. 

In  two  cases  the  middle  lobe  was  drawn  into  the  urethra  and  there 
removed.  In  both  of  these  cases  the  middle  lobe  was  of  a  peduncu- 
lated character  and  difficulty  was  experienced  in  getting  it  to  present 
into  one  of  the  lateral  cavities.  In  the  other  median  lobe  cases  it  was 
always  possible,  either  with  the  tractor,  or  with  the  index  finger  in 
the  urethra  to  enucleate  the  lobe  through  one  of  the  lateral  cavities, 
and  this  latter  method  is  much  preferable  in  that  the  base  of  the 
middle  lobe  is  much  more  completely  removed,  the  mucous  membrane 
is  not  usually  disturbed,  and  the  rather  abundant  hemorrhage,  which 
sometimes  follows  its  incision  along  with  the  middle  lobe,  is  thus  pre- 
vented. The  ideal,  which  is  to  make  no  tear  into  the  mucous  mem- 
brane adjacent  to  any  of  the  lobes,  can  very  frequently  be  accom- 
plished even  in  middle  lobe  cases,  and  in  several  instances  I  have 
been  able  to  enucleate  very  large  intravesical  lobes  without  even 
tearing  the  mucous  membrane  covering  them.  In  other  cases  small 
tears  have  been  made  and  in  very  rare  instances  a  small  area  of 
mucous  membrane  has  been  removed  with  the  median  lobe.     Tears  in 


84  Hugli  H.  Young. 

the  lateral  walls  of  the  urethra  have  been  a  much  more  common  occur- 
rence, but  in  only  two  or  three  cases  at  most  has  any  of  the  lateral 
walls  of  the  urethra  been  removed,  and  the  floor  of  the  urethra  and 
ejaculator}-  ducts  have  been  preserved  in  all  cases  except  those  six 
cases  mentioned  above  in  which  the  suburethral  portion  of  the  pros- 
tate was  removed  intentionalh-  (cases  55,  25,  145,  53,  TT,  57). 

It  is  interesting  to  note  that  three  of  these  patients  had  epididymitis 
after  the  operation,  of  which  two  went  on  to  abscess  formation,  and 
that  two  others  had  been  castrated  at  a  previous  operation.  These 
three  cases  prove  conclusively  that  preservation  of  the  ejaculatory 
ducts  is  of  very  great  importance  as  a  preventive  of  epidid}Tnitis. 

Anterior  lobes  were  drawn  down  into  lateral  cavities,  and  easily 
enucleated  in  five  cases  (50,  6,  120,  104,  65). 

■  In  two  cases  in  which  the  irregular,  almost  villous,  character  of  the 
intravesical  portion  of  the  prostate  led  me  to  suspect  malignancy,  an 
exploratory  suprapubic  operation  was  performed  (96,  97). 

In  two  cases  (89,  82),  associated  with  severe  stricture  of  the  urethra, 
a  median  perineal  incision  was  added  to  the  inverted  Y,  and  excision 
of  the  fibrous  tissue  in  the  region  of  the  stricture  carried  out. 

Vesical  calculi  were  removed  through  the  perineal  wound  after 
enucleation  of  the  prostatic  lobes  in  23  cases.  These  cases  are  de- 
scribed at  length  elsewhere. 

In  one  case  (30)  a  large  vesical  diverticulum  was  excised  through 
a  suprapubic  incision  (but  without  going  into  the  bladder)  before  the 
perineal  prostatectomy  was  done. 

Several  accidents  occurred  during  these  operations.  In  four  cases 
the  orderly  holding  the  stafE  in  the  urethra  allowed  the  beak  to  slip 
out  of  the  membranous  urethra,  and  when  instructed  to  introduce  the 
instrument  again  through  the  sphincter,  false  passages  were  produced, 
so  that  the  operator  found  the  instrument  outside  of  the  membranous 
urethra.  This  acident,  which  is  very  disagreeable  to  the  operator, 
should  never  occur  if  the  orderly  holding  the  instrument  takes  care 
not  to  allow  the  instrument  to  move  from  the  position  it  occupies 
when  entrusted  to  him  by  the  operator.  The  only  ujitoward  effect  of 
this  traumatic  rupture  of  the  bulbous  urethra  that  I  have  seen  has 
been  a  difficulty  in  introducing  the  catheter  after  operation  (in  two 
cases  requiring  filiforms,  but  no  definite  strictures  were  produced). 

In  four  cases  (101,  103,  71,  42)  a  tear  has  been  made  into  the 
rectum  in  exposing  the  posterior  surface  of  the  prostate.     Two  of 


study  of  llfO  Cases  of  'Perineal  Prostatectomy.  85 

these  cases  (71,  42)  had  previously  been  subjected  to  perineal  pros- 
tatectomy, there  was  a  large  amount  of  cicatrical  tissue  present,  the 
rectum  was  very  adherent  to  the  prostate,  and  although  great  care 
was  taken,  the  rectum  was  torn  into.  Both  of  these  cases  were  care- 
fully closed  with  layer  sutures  of  fine  silk,  and  one  healed  per  primam. 
In  the  other  two  cases  the  rectum  was  quite  adherent  to  the  prostate 
and  the  operator  endeavored  to  hasten  their  separation  by  the  forcible 
use  of  his  finger  and  the  tear  was  thus  made  into  the  rectum.  In 
both  of  these  cases  the  suture  of  the  rectum  was  successful.  These 
two  cases  are  very  instructive  in  showing  the  importance  of  not  at- 
tempting to  forcibly  push  the  rectum  away  from  the  posterior  surface 
of  the  prostate  with  the  finger  in  adherent  cases.  The  handle  of  the 
scalpel  is  a  much  safer  instrument,  and  if  it  is  always  directed  along 
the  posterior  surface  of  the  prostate  and  not  towards  the  rectum  no 
tear  should  ever  be  made  into  the  rectal  cavity.  In  some  cases,  owing 
to  intimate  fibrous  adhesions,  it  may  be  necessary  to  use  the  scalpel 
or  even  to  leave  a  small  portion  of  the  posterior  surface  of  the  prostate 
attached  to  the  rectum.  If  these  precautions  are  taken  a  tear  should 
never  be  made,  but  one  should  always  examine  the  rectum  with  a 
gloved  finger  inserted  through  the  anus  before  final  closure,  as  de- 
scribed in  another  portion  of  this  paper.  If  this  is  done  and  the 
levators  are  drawn  together  with  a  single  suture  of  catgut  into  their 
normal  position  in  front  of  the  rectum,  rectal  fistula  should  never 
follow. 

The  lateral  wall  of  the  urethra  was  intentionally  excised  in  one  case 
because  the  anterior  portion  of  one  of  the  lateral  lobes  contained  a 
markedly  indurated  nodule  which  was  slightly  suspicious  of  carcinoma, 
but  afterwards  proved  to  be  chronic  prostatitis  (128). 

Operative  Sliock. 

In  only  three  of  the  145  cases  was  there  severe  shock  after  the  opera- 
tion. These  cases  were  performed  under  spinal  anesthesia.  One 
patient  was  82,  one  76,  and  the  other  75  years  old,  and  all  were  very 
weak  subjects.  In  one  patient  the  pulse  was  quite  weak  after  the 
operation,  but  he  reacted  rapidly.  In  one  case  the  respiration  became 
very  rapid  after  the  operation.  In  one  case  there  was  a  slight  amount 
of  shock.  In  all  other  cases  there  was  absolutely  no  shock  from  the 
operation,  the  patient  being  in  good  condition  when  he  left  the  table 
and  after  his  return  to  the  ward. 


86  Hugh  H.  Young. 

The  surprising  manner  in  which  these  weak  old  men,  21  of  whom 
were  over  75  years  of  age  and  five  over  80,  have  stood  this  operation 
has  heen  to  me  indeed  very  surprising  not  to  say  remarkable.  Per- 
haps the  fact  that  the  patient  has  been  made  to  drink  water  in 
abundance  up  to  the  time  of  operation  and  in  frail  subjects  a  sub- 
mammary infusion  of  salt  solution  has  been  given  on  the  table,  has 
had  much  to  do  with  the  absence  of  shock.  The  position  of  the  patient 
has,  however,  I  believe  much  to  do  with  it,  as  in  the  exaggerated  dorsal 
or  lithotomy  position  the  blood  pressure  in  the  chest  and  head  remains 
strong  although  fairly  considerable  hemorrhage  may  occur. 

Spinal  AncBsthesia 

In  11  cases  spinal  anesthesia  was  employed  (cases  49,  50,  16,  23, 
55,  56,  54,  28,  25,  52,  33). 

All  of  these  patients  were  over  75  years  of  age  except  two  and  one 
of  these  was  in  desperate  shape  owing  to  pyonephrosis  (52).  Three 
cases  were  over  80  years  of  age.  The  reasons  for  employing  spinal 
anesthesia  were  old  age,  very  weak  condition,  the  fear  of  existing 
renal  impairment,  and  the  desire  to  avoid  pulmonary  complications 
after  the  operation.  As  remarked  above,  the  only  cases  in  which 
there  was  severe  shock  following  the  operation  were  among  these 
spinal  anesthesia  cases  (16,  54,  28).  The  shock  in  these  cases  came 
on  not  during  the  operation  but  after  removal  from  the  table,  and  I 
cannot  help  but  believe  that  it  was  in  some  way  connected  with  the 
method  of  anesthesia  as  it  has  not  been  present  in  any  cases  in  which 
ether  has  been  employed.  In  fact  one  of  the  surprising  results  of  this 
study  of  cases  has  been  the  demonstration  that  ether  anesthesia  could 
be  employed  with  such  perfect  results  in  patients  of  great  age,  in 
weakened  condition,  many  with  severe  renal  disorders,  cardiac  lesions, 
emphysematous  lungs,  and  otherwise  unfit  for  general  anesthesia  as 
usually  considered.  The  reasons  for  the  absence  of  lung  complica- 
tions is  I  believe  due  to  the  elevated  dorsal  position  which  effectually 
prevents  the  passage  of  mucus  into  the  trachea  while  the  patient  is  on 
the  operating  table.  I  have  yet  to  see  a  single  case  in  which  the  ether 
has  had  any  definite  effect  upon  the  renal  secretion  after  operation. 
Perhaps  this  might  occur  did  we  not  give  submammary  infusions 
either  on  the  table  or  after  return  to  the  ward  in  every  case,  and  fol- 
low these  up  by  considerable  dosage  of  water  by  mouth  or  by  rectum. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  87 

where  nausea  is  present.  The  result  of  this  discovery  has  been  that  I 
have  ceased  to  employ  spinal  anesthesia  because  I  can  see  no  objection 
to  the  use  of  ether. 

Duration  of  Operation. 

In  performing  the  operation  no  great  attempt  has  been  made  to 
work  with  extreme  rapidit}\  The  time  consumed  from  the  first  in- 
cision to  the  tying  of  the  last  suture  after  placing  the  tube  and  gauze 
drainage  has  varied  from  15  to  30  minutes^  22  minutes  being  about 
the  average.  An  effort  is  made  to  give  as  little  ether  as  possible,  the 
patient  being  placed  on  the  table  as  soon  as  anesthesia  is  complete 
and  ether  removed  considerably  before  the  end  of  operation. 

I  think  it  of  much  greater  importance  to  do  a  careful  operation^  to 
obtain  a  good  view  of  the  prostate,  to  do  no  injury  to  the  rectum,  to 
carefully  secure  the  edges  of  the  urethral  mucosa  before  attempting 
to  insert  the  tractor  and  to  see  what  you  are  doing,  to  be  sure  that 
all  obstructing  lobes  have  been  removed  and  that  no  nonobstructing 
but  important  anatomical  structure,  such  as  the  urethra  and  ejacu- 
latory  ducts,  have  been  removed,  than  to  try  to  make  record  time  in 
each  case.  ]\Iy  statistics  conclusively  show  that  there  is  no  reason 
why  prostatectomy  should  not  be  done  according  to  the  dicta  of 
modern  surgery,  and  not  blindly,  blunderingly  and  barbarously,  simply 
to  save  a  little  time. 

Characteristics  of  the  Prostatic  Loies  Removed  at  Operation. 

^°ment^®"  Slight.  Moderate  ^"^abfe!""  Great.   Very  great.  Huge 

Right     4  53  55  21  7  2  1 

Left    4  57  50  21  8  2  1 

Median    18  67  44  8  4  2  1 

Entire  intravesical 

portion    6  71  40  16  7  2  1 

In  the  tabulation  above,  the  four  cases  in  which  the  lateral  lobes 
were  not  at  all  enlarged  were  characterized  by  small  median  bar  ob- 
structions. In  these  cases  the  lateral  lobes  were  removed  (leaving 
however  a  fairly  broad  ejaculatory  bridge)  although  it  was  possible 
that  they  were  producing  very  little  obstruction.  It  seemed  best, 
however,  to  remove  the  three  portions  of  the  prostate  in  order  to  be 
certain  of  removing  all  obstructions.     In  two  of  these  cases  the  erec- 


88  Hugh  H.  Young. 

tions  have  returned  and  one  reports  sexual  intercouse  entirely  normal, 
the  other  has  not  attempted  intercourse,  and  the  third  and  fourth 
cases  are  now  in  the  hospital.  I  mention  these  results  as  showing 
that  there  is  no  objection  to  removing  the  lateral  lobes  even  if  appar- 
ently not  enlarged,  and  in  order  to  thoroughly  expose  the  median  bar 
it  is  important  that  this  should  be  done. 

In  the  above  statistics  the  statement  that  no  enlargement  of  the 
median  lobe  was  present  is  misleading.  It  should  read  that  no  por- 
tion of  the  median  lobe  was  removed  at  operation  in  18  cases.  This 
differs  so  markedly  with  the  cystoseopic  finding,  given  in  another  part 
of  this  paper,  in  which  only  four  cases  without  any  enlargement  of 
the  median  lobe  are  recorded  that  some  explanation  is  necessary. 

In  four  cases  (11,  120,  64,  5),  although  the  lateral  lobes  were  quite 
considerably  enlarged,  the  cystoscope  showed  no  median  enlargement, 
and  this  was  confirmed  by  the  operation  and  none  of  the  median  por- 
tion of  the  prostate  was  removed.  The  result  has  been  excellent  in  all 
of  these  cases.  In  four  cases  (23,  43,  48,  49)  the  cystoseopic  exam- 
ination was  not  satisfactory  on  account  of  hemorrhage,  but  in  three 
of  the  cases  the  result  has  been  excellent,  so  that  apparently  there  was 
very  little  median  obstruction  present.  In  the  fourth  case,  one  in 
whch  it  was  impossible  to  introduce  the  cystoscope  through  the  pos- 
terior urethra,  examination  at  the  time  of  operation  showed  appar- 
ently no  enlargement  of  the  median  enlargement  worthy  of  removal 
and  in  view  of  the  age  of  the  patient  (81  years)  it  was  thought  unwise 
to  prolong  the  operation.  The  patient  lived  30  days  and  died  of 
general  weakness  and  hypostatic  congestion  of  the  lungs,  but  his  blad- 
der did  not  functionate  properly  and  it  was  necessary  to  drain  it  with 
a  catheter.  Owing  to  the  fact  that  the  bladder  was  dilated  (with 
over  2000  cc.  residual  urine  before  operation)  it  was  impossible  to  say 
that  atony  of  the  bladder  was  not  the  chief  cause  of  failure  to  evacuate 
urine,  but  I  believe  that  there  must  have  been  some  obstruction  in 
the  median  portion  of  the  prostate  which,  although  slight,  should 
have  been  removed.  In  the  remaining  10  cases  (50,  10,  8,  83,  126, 
94,  3,  47,  15,  36)  although  the  c3^stoscope  showed  a  small  median 
bar,  after  removal  of  the  lateral  lobe  examination  of  the  median 
portion  seemed  to  show  that  there  was  not  sufficient  enlargement  in 
this  region  to  cause  obstruction,  and  as  it  was  impossible  to  make  this 
portion  present  into  one  of  the  lateral  cavities  with  the  tractor  it 
was  thought  unnecessary  to  split  open  the  urethra  and  excise  this 


study  of  lJj.5  Cases  of  'Perineal  Prostatectomy.  89 

median  poxtion.  Accordingly  nothing  was  removed  from  this  region. 
The  results  obtained  in  six  eases  show  that  this  decision  was  entirely 
correct,  but  in  the  first  five  cases  mentioned  above  there  is  a  question 
whether  the  results  obtained  might  not  have  been  better  had  the 
median  portion  been  excised.  One  of  these  patients  although  re- 
lieved of  the  complete  retention,  from  which  he  suffered  before  opera- 
tion, complained  of  severe  pain  in  the  wound  during  the  three  weeks 
he  lived  after  operation  (83).  One  case  (50)  had  an  atonic  over  dis- 
tended bladder  with  1100  cc.  residual  urine  before  operation  and  the 
residual  is  now  300  cc.  and  the  cystoscope  shows  a  small  median  bar, 
so  that  I  do  not  believe  the  obstruction  was  completely  removed. 
The  other  two  cases  consider  themselves  greatly  improved  but  suffer 
from  slight  frequency  of  urination. 

Another  case  (126)  who  also  had  a  very  large  residual  urine  (9-10 
cc.)  now  had  150  cc.  residual  urine  although  he  does  not  get  up  at  all 
at  night  to  urinate  and  micturition  is  normal. 

Although  there  is  definite  evidence  of  residual  urine  after  the 
operation  in  but  three  cases,  all  of  whom  had  about  1000  cc.  residual 
urine  and  very  weak  atonic  bladders  before  operation,  I  feel  certain 
that  even  better  results  might  have  been  obtained  by  the  routine 
removal  of  the  median  portion  of  the  prostate  in  these  cases  although 
it  did  not  seem  enlarged  at  operation,  and  in  the  future  this  shall  be 
my  practice. 

A  review  of  the  cases  in  which  the  lateral  and  median  portions  re- 
moved at  operation  were  slight  shows  many  very  severe  cases  of  ob- 
struction. A  large  number  of  these  patients  had  complete  retention 
of  urine  and  depended  entirely  upon  the  catheter,  and  in  others 
catheterization  was  necessary  owing  to  a  large  amount  of  residual 
urine  and  great  difficulty  and  frequency  of  urination.  In  this  class 
there  were  probably  more  cases  of  contracture  of  the  bladder  and 
small  residual  urine,  and  more  cases  associated  with  calculus  than 
among  the  large  prostates,  but  in  every  case  operated  there  was  definite 
evidence  of  serious  obstruction  present  and  the  excellent  results 
obtained  show  the  wisdom  of  intervention.  In  these  cases  of  slight 
enlargement  of  the  lateral  lobes  I  usually  found  very  little  difficulty 
in  removing  the  lateral  lobes  each  in  one  piece.  By  making  the 
initial  capsular  incisions  deep  the  lobes  are  easily  freed  from  the 
urethra  and  no  difficulty  is  experienced  in  separating  them  from  the 
capsule,  but  the  vesical  end  of  each  lobe  is  often  quite  adherent  and  in 
Vol.  XIV.— 7. 


90  Hugh  H.  Young. 

some  cases  cannot  be  enucleated  with  the  finger,  in  such  cases  I  have 
found  the  use  of  broad  sharp  periosteal  elevator  of  considerable  use  in 
freeing  the  deeper  portions.  In  the  case  of  a  very  small  median  lobe, 
when  pedunculated  it  has  usually  been  an  easy  matter  to  cause 
it  to  present  into  one  of  the  lateral  cavities  with  the  tractor  or  the 
finger  in  the  urethra,  but  in  the  case  of  a  small  fibrous  median  bar  it 
has  occasionally  been  necessary  to  split  the  urethra  along  one  of  the 
lateral  walls  and,  thus  exposing  the  median  portion  of  the  prostate, 
to  grasp  it  with  tooth  forceps  and  excise  it  with  its  mucous  covering 
through  the  lateral  cavity  and  urethra  combined.  Several  recent 
cases  (133,  137,  143,  141)  have  shown  the  importance  of  this  method 
of  technique.  Whenever  it  has  been  impossible  to  engage  the  median 
portion  of  the  prostate  with  the  tractor,  and  the  index  finger  meets 
with  a  firm  cicatricial  ring  around  the  prostatic  orifice,  although  no  en- 
largement may  be  evident  it  is  extremely  important  that  the  median 
portion  should  be  excised  to  prevent  the  continuance  of  obstruc- 
tion as  in  case  (126).  By  the  technique  mentioned  above  the  ejacu- 
latory  ducts  are  not  disturbed  and  only  a  small  bit  of  mucous  mem- 
brane at  the  vesical  orifice  is  removed.  The  absence  of  epididymitis 
following  the  cases  operated  upon  by  this  technique  and  its  presence  in 
all  cases  in  which  the  suburethral  method  was  used,  show  conclusively 
that  the  former  is  greatly  to  be  preferred. 

As  regards  the  cases  of  moderate  hypertrophy  there  is  little  to  be 
said.  The  enucleation  especially  of  the  median  portion  has  nearly 
always  been  easier  than  in  the  cases  of  slight  hypertrophy.  As  seen 
in  the  above  table  these  cases  form  about  one-third  of  the  entire  num- 
ber of  prostatic  hypertrophy  and  along  with  the  cases  of  slight  en- 
largement form  about  70%. 

In  the  cases  described  as  considerable  enlargements  it  is  noticed 
that  the  portion  affected  was  more  commonly  the  lateral  than  the 
median,  and  the  same  is  true  with  the  great  hypertrophies.  In  one 
case  (11)  in  which  there  was  a  considerable  hypertrophy  of  each  of 
the  lateral  lobes,  there  was  no  enlargement  at  all  of  the  median  portion 
of  the  prostate,  the  intravesical  portions  of  the  lateral  lobes  being 
flattened  against  each  other  like  two  halves  of  an  orange.  The  urethra 
in  this  case  was  about  5  cm.  wide. 

Seven  cases  (65,  96,  20,  29,  122,  13,  114)  have  been  classed  as 
great  enlargements.  In  these  cases  there  was  an  involvement  of 
both  lateral  and  median  portions  of  the  prostate  in  an  extensive  intra- 


study  of  IJfB  Cases  of  'Perineal  Prostatectomy.  91 

vesical  outgrowth.  The  weight  of  tissue  removed  in  these  cas6s 
varied  from  80-G  to  100-G. 

Two  cases  (109,  73)  have  been  classed  as  very  great  hypertrophies. 
Here  also  all  three  portions  of  the  prostate  were  involved,  forming  a 
very  large  intravesical  mass,  the  tissue  removed  weighing  150  and 
145-G. 

In  one  case  (16)  the  prostate  has  been  classed  as  4iuge,  the  intra- 
vesical portion  of  the  prostate  forming  a  mass  about  9  cm.  in  diameter 
and  weighing  when  removed  210-Gr.  In  none  of  these  cases,  although 
the  prostatic  enlargement  was  largely  intravesical  and  of  great  size, 
was  an}^  special  difficulty  experienced  in  enucleating  the  prostatic 
lobes  through  the  perineum,  in  fact  the  operation  was,  in  many  cases, 
much  easier  than  some  of  the  small  fibrous  prostates.  In  most  cases 
the  lateral  lobes  have  been  removed  each  in  one  piece  and  the  median 
lobe  in  one  or  two  pieces,  though  in  some  instances  they  have  come 
away  in  several  large  lobules.  In  the  case  weighing  240-G.  the  pros- 
tatic mass  was  so  large  that  it  could  not  be  drawn  between  the  ischio- 
pubic  rami  and  the  tractor  was  so  small  that  it  would  not  take  hold 
upon  the  huge  intravesical  mass  after  a  portion  had  been  removed. 
It  was  necessary  to  draw  down  large  lobules  with  forceps  and 
enucleate  them  separately.  Had  the  patient  been  under  general 
anesthesia  abdominal  pressure  would  have  been  a  great  assistance  in 
this  case,  but  he  would  not  allow  it.  In  nearly  all  other  cases  of  the 
great  hypertrophies  the  ordinary  tractor  has  been  entirely  sufficient 
to  engage  and  draw  down  the  intravesical  portions,  but  in  two  cases 
of  very  large  pedunculated  median  lobes  it  was  necessary  to  introduce 
the  finger  into  the  bladder  through  the  urethra  for  assistance  in  the 
traction. 

A  review  of  these  cases  show  conclusively  that  even  the  very  great- 
est intravesical  prostatic  enlargements  can  be  removed  through  the 
perineum  with  ease  and  without  destroying  the  ejaculatory  ducts  or 
removing  more  than  a  very  small  part  of  the  mucous  membrane 
covering  the  median  lobe.  At  one  time  I  was  of  the  opinion  that 
cases  of  this  character  would  be  unsuitable  for  perineal  operation, 
but  I  am  now  convinced  that  complications  of  a  different  character 
must  be  present  before  it  can  be  said  it  is  advisable  to  attack  the 
prostate  through  the  suprapubic  route.  The  convalescence  in  these 
cases  has  been  very  satisfactory,  the  results  obtained  excellent,  and 


92  Hugh  H.  Young. 

they  furnish,  I  believe,  the  strongest  evidence  of  the  great  advantages 
of  the  perineal  route  as  a  routine  operation  for  the  removal  of  ob- 
structing prostates  regardless  of  their  size. 

Operations  in  the  'Presence  of  Vesical  CaJcuIi. 

Vesical  calculi  were  present  in  25  cases  (23,  29,  32,  33,  36,  45,  47, 
48,  62,  66,  70,  81,  83,  85,  92,  94,  101,  104,  114,  115,  116,  122,  135, 
140,  144). 

In  13  cases  one  stone  was  found,  in  five  cases  two  stones,  in  three 
cases  three  stones,  and  in  one  case  each  four,  five,  seven,  and  "  several  " 
stones.  In  most  cases  the  stones  were  not  very  large,  and  in  several 
cases  quite  small.  In  two  cases  (47  and  140)  the  stones  were  quite 
large.  In  one  of  these,  although  the  stone  was  a  rough  spiculated 
oxalate  calculus,  the  patient  had  been  almost  entirely  free  from  pain. 

In  one  case  (115)  the  calculus  was  quite  small  and  was  apparently 
lost  in  a  blood-clot  which  was  removed  from  the  bladder  in  searching 
for  the  calculus.  It  seems  probable  that  it  was  removed  since  the 
patient  has  had  an  excellent  result  and  cystoscopy  is  negative. 

In  case  ISTo.  114,  although  a  large  calculus  had  been  distinctly  seen 
with  the  cystoscope,  repeated  attempts  by  the  writer  and  his  assist- 
ants failed  to  find  it  at  operation,  although  prolonged  searchings 
were  made,  and  the  wound  was  closed  without  removing  the  calculus. 
The  search  had  been  so  careful  that  I  felt  sure  the  cystoscope  had 
deceived  me.  The  patient  returned  several  months  later  complaining 
of  pain  and  the  c^'stoscope  again  showed  a  very  large  calculus,  which 
was  removed  suprapubically. 

I  believe  the  failure  to  find  the  calculus  was  due  to  the  fact  that  its 
large  size  made  it  difficult  to  encompass  with  calculus  forceps,  and  a 
coating  of  blood  prevented  us  from  obtaining  crepitus  with  the  instru- 
ments. I  do  not  remember  whether  a  search  was  made  with  a  finger 
inserted  through  the  urethral  orifice  into  the  bladder.  Such  a  pro- 
cedure should  have  detected  the  calculus  in  a  contracted  bladder.  At 
any  rate  it  was  an  unpardonable  mistake  to  desist  without  finding  the 
calculus  when  it  had  been  so  clearly  seen  with  the  cystoscope. 

In  the  other  cases  no  difficulty  was  encountered  in  extracting  cal- 
culi through  the  perineum.  When  they  were  small  they  were  some- 
times removed  through  the  prostatic  urethra  without  tearing  its  walls. 
In  a  few  other  cases  it  had  to  be  dilated  before  forceps  could  be  intro- 
duced or  calculi  removed. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  93 

In  most  instances,  however,  it  was  thought  best  to  divide  the 
urethra  along  a  lateral  wall  thus  throwing  the  urethra  and  the  capsu- 
lar space  on  that  side  into  a  common  cavity  (as  described  in  the  chap- 
ter on  operative  technique)  through  which  it  was  an  easy  matter  to 
remove  calculi  5  or  6  cm.  in  size.  In  only  one  case  was  it  necessary 
to  do  more  than  dilate  the  vesical  orifice,  and  in  this  ease  (47)  a 
short  incision  was  made  through  the  vesical  wall  which  was  brought 
well  into  view  by  traction  with  the  stone  grasped  by  the  forceps.  By 
making  a  longer  incision  a  much  larger  calculus  could  have  been 
removed. 

I  therefore  feel  justified  in  saying  that  the  presence  of  even  very 
large  calculi  should  not,  as  a  rule,  be  considered  a  contraindication  to 
perineal  prostatectomy. 

The  markedly  lower  mortality  shown  by  the  perineal  route  in  these 
cases  (see  another  article  in  Volume  XIII  on  perineal  lithotomy)  is  a 
strong  argument  for  adoption  of  the  perineal  route  when  stones  are 
present,  unless  they  be  within  diverticula  with  small  orifices. 

E.    THE   CONTALESCENCE. 

In  the  preceding  chapter  we  have  described  the  way  in  which  the 
patient  reacted  after  the  operation.  The  subsequent  convalescence 
has  in  the  vast  majority  of  cases  been  remarkably  simple  and  rapid. 
In  all  but  three  cases  (barring  the  fatal  and  rectal  fistula  cases)  the 
patient  was  out  of  bed  within  a  week.  As  a  rule  the  patient  was  put 
in  a  wheel-chair  on  the  second  or  third  day  after  the  operation  and 
carried  out  on  a  veranda,  and  within  a  week  most  patients  have  been 
walking  about  the  ward.  During  the  past  two  years  it  has  been  my 
custom  to  remove  the  gauze  from  the  wound  on  the  morning  after  the 
operation,  and  the  tubes  have  been  removed  on  the  same  day  or  the 
day  following.  Since  following  this  custom  the  rapidity  of  the  con- 
valescence has  been  remarkabh'  better,  and  the  fistulfe  have  closed 
much  more  quickly.  For  example,  in  40  cases  operated  on  in  the  two 
years  from  1903  to  May  25,  1904,  there  were  11  cases  in  which  the 
fistula  persisted  more  than  two  months.  Whereas,  during  the  two 
years,  1904  to  1906,  105  cases  have  been  operated  on  with  only  nine 
cases  in  which  the  fistula  persisted  longer  than  two  months.  The 
same  thing  is  true  in  regard  to  the  length  of  stay  in  the  hospital. 
In  1902  to   1904,  out  of  40  patients  12  remained  in  the  hospital 


94  Hugh  H.  Young. 

over  50  da^'s;  whereas,  in  the  12  montlis,  June,  1905,  to  June, 
1906,  among  50  cases  there  was  no  one  in  the  hospital  as  long  as  50 
days,  and  only  two  cases  over  40  days.  Fifty  per  cent  did  not  remain 
longer  than  22  days,  and  two  cases  left  within  two  weeks  after  the 
operation. 

In  seven  cases  the  urine  began  to  flow  through  the  anterior  urethra 
on  the  second  day,  in  four  cases  on  the  third  day,  in  10  cases  on  the 
fourth  day,  in  15  cases  during  the  second  week,  in  12  cases  during  the 
third  week,  and  in  one  case  during  the  fourth  week.  In  the  great 
majority  of  cases  urine  passed  through  the  penis  during  the  first  week, 
and  inside  of  two  weeks  there  was  only  a  slight  escape  of  urine  through 
the  perineal  fistula. 

Interval  urination  T\-ith  fairly  good  control  has  been  established  re- 
markably early  in  the  convalescence.  In  four  cases  in  which  no  drain- 
age tubes  were  used  the  patient  had  control  at  once  and  voided  urine  at 
stated  intervals  beginning  immediately  after  the  operation.  In  six 
cases  in  which  tubes  were  employed,  voluntary  urination  at  intervals 
was  established  on  removal  of  the  tubes  on  the  second  or  third  day. 
The  same  thing  probably  occurred  in  many  other  cases,  but  unfortu- 
nately accurate  notes  on  this  point  have  been  kept  in  only  a  compara- 
tively small  number  of  cases.  In  16  other  cases,  in  which  notes  have 
been  kept,  interval  urination  was  established  between  the  third  and 
eighth  day,  and  although  the  patient  did  not  void  all  of  the  urine 
through  the  meatus  he  has  been  able  to  retain  urine  for  a  definite 
period  and  frequently  has  employed  a  commode  rather  than  allow 
the  urine  to  escape  into  the  perineal  dressings.  The  latter  plan  has 
added  considerably  to  the  comfort  of  the  patient  as  the  presence  of 
dressings  wet  with  urine  is  always  a  source  of  annoyance. 

The  establishment  of  early  control  and  voluntary  urination  shows 
conclusively  that  in  the  operation  which  I  have  emplo5^ed  the  vesical 
sphincter  is  not  greatly  injured,  and  this  fact  has  been  frequently 
demonstrated  at  operation,  when  after  the  removal  of  even  large  me- 
dian and  lateral  lobes  an  examination  with  the  finger  has  demonstrated 
the  vesical  sphincter  entirely  preserved,  though  often  dilated.  The 
fact  that  the  entire  operation  is  done  between  the  external  and  inter- 
nal sphincters  without  destroying  either  explains,  I  believe,  the  reason 
why  incontinence  never  follows  this  operation,  whereas  it  occasionally 
foUows  suprapubic  prostatectomy  in  which  the  internal  sphincter  is 
considerably  injured,  and  perineal  prostatectomy  through  the  ordinary 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  95 

perineal  section  in  which  the  external  sphincter  is  divided  and  often 
considerably  lacerated. 

During  the  period  in  -vrhich  the  fistula  is  small  hut  still  open  there 
is  a  marked  difference  in  the  comfort  of  the  patient  in  perineal  and 
suprapubic  prostatectomy  cases.  In  the  former  the  urine  is  voided 
at  intervals  through  the  urethra  at  which  time  a  small  amount  escapes 
through  the  perineal  fistula,  but  by  using  the  water-closet  the  patient 
is  able  to  avoid  any  soiling  of  his  clothes  and  it  is  unnecessary  to 
wear  absorbing  dressings,  whereas  in  the  latter  the  urine  constantly 
escapes  through  the  suprapubic  fistula  generally  until  its  final  closure 
which  is  usually  longer  delayed  than  in  perineal  prostatectomy  cases. 

Complications  During  ConvaUscence. 

Epididymitis  occurred  as  a  sequel  to  the  operation  in  20  cases. 
In  15  cases  it  was  slight  and  it  involved  only  one  testicle  in  all  but 
two  cases.  In  many  cases  it  was  merely  a  slight  transitory  enlarge- 
ment of  the  epididymis  which  was  moderately  tender  and  rapidly  dis- 
appeared under  applications  of  ice  and  in  several  instances  without 
any  treatment.  In  five  cases  the  inflammation  went  on  to  abscess  for- 
mation and  required  incision  after  which  it  promptly  healed.  In  the 
50  cases  operated  on  during  the  past  year  epidid}Tnitis  has  occurred 
six  times,  in  all  cases  slight  and  not  requiring  operative  interference. 
As  remarked  before,  three  of  the  cases  of  epididymitis  were  in  the 
cases  in  which  the  suburethral  method  of  removing  the  median  por- 
tion of  the  prostate  was  employed.  Excluding  the  atypical  cases  we 
have  then  138  cases  in  which  the  tj-pical  operation  was  employed  with 
epididymitis  as  a  complication  in  16  cases  (in  three  of  which  abscess 
formation  occurred),  12%.  This  corresponds  exactly  to  the  figures 
for  the  past  year. 

When  we  consider  the  fact  that  20%  of  all  the  cases  had  had  epi- 
didymitis before  coming  to  the  hospital,  and  that  those  cases  coming 
on  after  operation  occurred  usually  during  the  second  or  third  week 
of  the  disease  we  see  how  little  the  operation  had  to  do  with  it.  The 
fact  that  it  occurred  in  all  cases  but  one  in  which  the  ejaculatory 
ducts  were  removed  shows  conclusively  that  the  conservation  of  these 
ducts  is  of  very  great  importance  as  a  preventative  of  epididymitis. 

Suppuration  of  ivound. — The  sutured  portion  of  the  wound  became 
infected  and  partially  broke  down  in  three  cases  and  completely  broke 


96  Hugli  H.  Young. 

down  in  three  cases.  In  the  other  cases  although  the  packed  portion 
of  the  wound  became  infected  from  preexisting  cystitis  the  sutured 
wound  healed  by  first  intention.  This  has  been  to  me  one  of  the  most 
remarkable  findings  after  this  operation,  for  it  seems  wonderful  that 
wounds  could  heal  so  well  when  immediately  adjacent  to  an  abundant 
infection  and  suppuration,  and  the  contrast  between  these  cases  and 
those  in  which  suprapubic  prostatectomy  was  performed  is  very  great. 
Since  it  has  been  my  practice  to  remove  the  gauze  on  the  day  after  the 
operation  and  the  tubes  on. the  second  day  the  wounds  have  healed 
much  more  rapidly. 

Post-operative  hemorrhage  occurred  in  four  cases,  in  two  on  the 
second  day,  after  removal  of  the  gauze  and  in  both  cases  of  moderate 
degree  and  readily  controlled  by  repacking  the  wound.  In  one  case 
(89)  severe  post-operative  hemorrhage  occurred  from  an  extensive 
vesical  ulcer  which  had  been  curetted  at  operation,  and  resulted  in 
death  on  the  eighth  day.  In  one  case  (9)  there  was  moderate  hemor- 
rhage on  the  night  after  the  operation  and  an  assistant  thought  it 
necessary  to  forcil^ly  pack  the  wound  with  gauze.  As  a  result  necrosis 
of  the  rectal  wall  followed.  It  may  be  remarked  here  that  a  certain 
amount  of  hemorrhage  may  always  be  expected  after  the  operation, 
and  one  should  not  })e  surprised  if  it  is  more  abundant  than  he  is 
accustomed  to  see,  especially  in  operations  where  it  is  possible  to 
ligate  all  bleeding  points. 

As  a  rule  the  irrigation  fluid  comes  away  slightly  stained  with  blood 
for  several  hours  and  in  cases  where  the  mucous  membrane  covering 
a  median  lobe  has  been  lacerated  in  its  removal,  there  may  be  fairly 
abundant  hemorrhage,  but  a  hot  irrigation  will  generally  cause  a  ces- 
sation of  the  bleeding.  As  a  matter  of  fact  hemorrhage  has  not  been 
a  matter  of  alarm  in  any  but  the  single  fatal  case  mentioned  above. 

Recto-urethral  fistulce  followed  the  operation  in  seven  cases  and  are 
discussed  at  length  in  another  paper  in  this  volume. 

Phlebitis  of  the  veins  of  the  thigh  occurred  in  two  cases.  Purpura 
in  one  case,  pleurisy  in  one  case,  cholecystitis  in  one  case,  severe  pain 
in  the  back  which  had  been  present  before  operation  persisted  after 
operation  in  one  case  (130).  In  one  case  the  exit  tube  became  blocked 
in  some  way  and  the  scrotum  became  distended  with  salt  solution, 
and  two  small  incisions  were  required  to  evacuate  it.  The  patient 
(139)  made  a  satisfactory  convalescence,  and  although  a  weak  old 
man,  left  the  hospital  on  the  29th  day. 


study  of  IJf-o  Cases  of  'Perineal  Prostatectomy.  97 

In  two  cases  internes  failed  to  remove  a  portion  of  the  gauze  pack- 
ing, in  one  case,  until  the  fifth  week  (12).  In  the  other  case  (7) 
all  of  the  gauze  was  thought  to  have  been  removed  and  the  patient 
was  discharged  on  the  20th  day.  The  fistula  closed  on  the  30th  day 
and  the  patient  had  no  discomfort  with  exception  of  a  urethral  dis- 
charge until  five  months  later  when  a  perineal  abscess  formed.  After 
that  a  perineal  fistula  persisted.  An  operation  was  performed  10 
months  after  the  prostatectomy  in  order  to  close  it,  and  greatly  to 
the  surprise  of  the  operator  a  large  piece  of  gauze  was  found  within 
one  of  the  prostatic  capsules.  After  that  the  perineal  fistula  promptly 
healed. 

Stricture  of  the  urethra. — I  have  yet  to  see  a  definite  case  of  stricture 
of  the  urethra  following  this  operation,  and  I  see  no  reason  why  one 
should  occur.  The  small  linear  incision  which  is  made  in  the  mem- 
branous urethra  back  of  the  sphincter  should  never  lead  to  the  forma- 
tion of  stricture  as  the  coaptation  of  the  two  edges  of  the  wound 
should  restore  the  urethra  to  its  normal  caliber. 

In  one  case  (25)  in  which  the  floor  of  the  urethra  was  removed 
along  with  the  median  portion  of  the  prostate  (by  the  suburethral 
method)  the  patient's  physician  reports  that  he  found  a  stricture  which 
was  easily  dilated  with  sounds.  In  two  cases  in  which  rupture  of  the 
bulbous  urethra  has  been  produced  by  an  orderly  holding  the  urethro- 
tomy staff,  some  difficulty  has  been  experienced  in  passing  a  catheter 
after  the  operation,  but  no  definite  stricture  has  been  present.  As 
stated  elsewhere,  I  have  not  found  it  necessary  to  pass  sounds  after 
the  operation,  and  in  no  cases,  except  the  one  mentioned  above  have 
they  been  employed.  In  fact  I  believe  it  is  very  important  to  avoid 
instrumentation,  and  usually  pass  no  instrument  except  a  small  silver 
catheter  to  determine  whether  any  residual  urine  is  present  on  the 
departure  of  the  |)atient,  and  in  many  cases  in  which  urination  is 
apparently  normal  as  regards  interval  and  force  of  stream  and  there 
is  every  evidence  that  the  obstruction  has  been  removed,  I  have  not 
even  passed  the  catheter. 

In  conclusion  I  may  say  that  the  convalescence  even  in  the  serious 
cases  is  usually  a  very  simple  and  rapid  affair.  With  the  use  of  an 
infusion  after  the  operation  and  copious  imbibition  of  water  beginning 
as  soon  as  possible,  early  purgation,  getting  the  patient  out  of  bed  as 
soon  as  possible,  and  the  early  removal  of  gauze  and  tube  drainage, 
the  patient  is  usually  walking  about  the  hospital  and  voiding  urine  at 


98 


Hugli  H.  Young. 


stated  intervals  declaring  that  he  feels  well  enough  to  leave  at  the 
end  of  the  first  week. 


Length 

of  Time  in  Hospital. 

The  following  table  gives  the  duration  of 

the  time  during  which 

the  patient  remained  in  the 

hospital  after  operation. 

4  cases 

between  10  and  14 

days. 

20      " 

"       15     "     19 

36       " 

"       20     "     24 

25       " 

"       25     "     29 

16       " 

"       30     "     34 

5       " 

"       35     "     39 

9       " 

"       40     "     49 

6       " 

"       50     "     59 

12       " 

over         60 

Fifty  per  cent  of  the  cases  left  the  hospital  within  25  days  after 
the  operation,  and  only  21%  remained  longer  than  one  month. 
Thirty-two  cases  remained  in  the  hospital  longer  than  35  days.  Many 
of  these  were  very  weak  patients,  in  poor  condition  before  the  operation, 
who  convalesced  slowly.  In  five  cases  the  cause  of  delay  was  a  recto- 
urethral  fistula.  In  five  cases  it  was  due  to  the  presence  of  a  supra- 
pubic fistulas  which  was  difficult  to  heal.  In  nine  cases  it  was  due 
to  epididymitis,  in  three  of  which  abscess  formed  and  incision  was 
necessary.  In  seven  cases  it  was  due  to  a  tardy  closure  of  the  perin- 
eal fistula,  in  two  cases  to  old  stricture  of  the  urethra  which  required 
dilatation.  In  one  case  each  to  cholecystitis,  tabes  dorsalis,  a  burn 
from  a  hot-water  bag  on  the  leg,  a  fragment  of  calculus  left  in  the 
bladder,  and  a  piece  of  gauze  packing  left  in  the  perineum  for  four 
weeks.  In  one  case  (50)  the  patient  remained  in  the  hospital  37 
days  owing  to  an  imperfect  result,  there  being  200  cc.  residual  urine 
present  which  caused  urine  to  be  voided  at  intervals  of  two  hours, 

A  review  of  these  cases  shows  that  the  delay  was  due  in  many  cases 
to  causes  not  attributable  to  the  operation,  such  as  previous  suprapubic 
fistula,  stricture  of  the  urethra,  cholecystitis,  tabes  dorsalis,  gauze 
left  in  the  wound,  a  burn  on  the  leg,  in  all  eleven  cases.  There  was 
also  one  case  of  suppurative  epididymitis  which  was  present  before 
operation  and  which  was  the  cause  of  the  patient  remaining  in  the 
hospital  for  39  days  (61). 

In  the  remaining  20  cases  the  prolonged  stay  was  due  more  or  less 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy. 


99 


directly  to  the  operation,  the  most  important  of  which  was  recto- 
urethral  fistula,  but  since  the  technique  has  been  modified  so  as  to 
include  an  approximation  of  the  levator  muscles  this  complication  has 
disappeared,  and  during  the  past  year  in  50  cases  we  find  only  six 
eases  have  remained  longer  than  35  days. 

Closure   of   the   fistula. — The   following   table   shows   the   time   of 
closure  of  the  perineal  fistula : 

4  cases  between 
21 
31 
17 

7 

7 

3 

6 

1 
13       "      over 
17       "      fistula  closed  but  time  not  noted. 

6       "  "       still  open.     (2  recent.) 

10      "      died  before  closure  of  fistula. 

2       "      operated  during  the  past  3  weeks. 


"   10  ' 

14   " 

"   15  ' 

19   " 

"   20  ' 

24   " 

"   25  ' 

29   " 

"   30  ' 

34   " 

"   35  ' 

39   " 

"   40  ' 

49   " 

"   50  ' 
an 

59   " 

Total  145 

As  stated  above  there  are  present  only  four  cases  of  permanent 
perineal  fistulge.  One  of  these  patients  (26)  had  a  recto-urethral 
fistula  after  the  operation  for  which  two  subsequent  operations  were 
performed  (not  the  most  recent  method,  however).  There  is  pres- 
ent now  a  pin-point  urinary  fistula  through  which  only  occasionally 
a  few  drops  of  urine  escape.  The  second  case  (12)  is  the  one  in 
which  a  piece  of  gauze  was  discovered  in  the  wound  four  weeks  after 
the  operation.  A  pin-point  fistula  now  persists  through  which  only 
two  or  three  drops  of  urine  escape  during  each  urination.  In  both 
of  these  cases  the  patients  sufl'er  no  discomfort  and  refuse  treatment 
for  the  fistulge.  The  third  case  (14)  is  one  in  which  I  operated  for 
Professor  Casper  in  Berlin.  He  reported  one  year  later  that  a 
minute  fistula  was  present  through  which  a  small  amount  of  urine 
escaped  during  urination.  The  fourth  case  (44)  is  one  in  which  the 
median  portion  of  the  prostate  was  not  completely  removed,  and  400 
cc.  of  residual  urine  are  still  present.  The  fistula  is  minute  and  only 
a  small  amount  of  urine  escapes  through  it  during  urination.     In  two 


100  Hugli  H.  Young. 

cases  (122,  136)  the  operation  was  performed  six  and  two  months  ago 
respective!}',  and  the  fistulse  are  healing  under  treatment. 

Among  the  10  patients  who  died  before  closure  of  the  fistula  three 
(55,  24,  107)  lived  5,  12,  and  10  months,  respectivel)^  after  the 
operation  and  died,  two  of  accident  and  one  from  pyonephrosis.  In 
these  three  cases  small  perineal  fistula  were  still  present.  The  other 
seven  cases  died  from  8  to  31  da^'s  after  the  operation,  and  their  his- 
tories are  given  in  detail  later  on  (see  mortality). 

In  the  two  cases  which  are  still  in  the  hospital  the  fistula  has  not 
healed,  but  a  month  has  not  yet  elapsed. 

In  IT  cases  the  fistula  closed  shortly  after  leaving  the  hospital,  but 
unfortunately  we  have  been  unable  to  learn  exactly  when  the  final 
closure  occurred. 

As  remarked  above,  fistulse  cannot  be  considered  complications  of 
any  moment  after  perineal  prostatectomy.  In  62%  of  the  cases  the 
fistula  has  closed  within  24  days  after  the  operation,  and  during  the 
past  year  in  the  50  cases  operated  it  was  closed  within  24  days  in 
T5%  of  the  cases.  The  fistula  at  the  end  of  two  weeks  has  usually 
been  only  a  very  small  affair  through  which  a  little  urine  would 
escape  during  urination,  and  those  wliich  have  persisted  longer  than 
24  days  have  been  of  pin-point  size,  allowed  the  passage  of  only 
a  few  drops  of  urine,  and  have  not  been  enough  to  cause  the  patients 
more  than  slight  annoyance.  There  has  been  no  case  of  perineal 
fistula  in  which  there  has  been  a  continous  leakage  of  urine,  such  as  is 
present  in  nearly  all  cases  of  suprapubic  fistula  until  the  very  time  of 
final  closure. 

The  persistance  of  the  fistula  has  usually  been  due  to  suppurative 
conditions  in  the  urinary  tract  and  perineal  wound.  In  many  of 
these  cases  the  bladder  infection  has  been  very  great,  and  this  con- 
dition has  been  communicated  to  the  perineal  wound  and  led  to  the 
formation  of  unhealthy  granulations.  In  two  cases  urethral  stric- 
tures were  responsible  for  the  delay  in  the  closure  of  the  fistulte,  and 
in  cases  where  the  rectum  has  broken  down  the  perineal  fistulas  have 
always  persisted  until  the  rectum  was  closed.  The  employment  of 
suprapubic  drainage  in  these  cases  has  been  followed  by  a  prompt 
closure  of  the  perineal  fistula. 

In  many  of  the  cases  in  which  the  fistulse  were  slow  in  healing,  the 
patient  has  left  the  hospital  too  soon  and  has  not  received  appropriate 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  101 

treatment  after  return  home.  With  the  exception  of  one  case  (44) 
I  have  been  able,  in  every  instance,  to  hasten  the  closure  of  fistulge 
by  occasional  curettage  with  the  gimlet  curette  (Fig.  39^)  and  applica- 
tions of  nitrate  of  silver. 

F.    IMMEDIATE  RESULT  OF  OPERATION.      CONDITION  ON  DISCHARGE. 

Voluntary  urination  was  established  in  every  case  by  the  operation. 
On  discharge  from  the  hospital  there  was  not  a  single  case  that  re- 
quired catheterization,  although  on  entrance  the  catheter  was  neces- 
sary in  134  cases,  64  of  whom  had  complete  and  70  incomplete  re- 
tention of  urine. 


Fig.  39\ 

This  restoration  of  the  power  of  voluntary  urination  in  every  case 
is  indeed  remarkable  when  we  consider  that  in  21  cases  there  were  over 
500  cc.  residual  urine  present,  in  five  cases  over  1000  cc,  and  that  one 
patient  had  used  the  catheter  for  seven  years,  two  for  eight  years,  one 
for  nine  years,  and  one  for  14  years,  the  retention  of  urination  being 
complete  during  these  periods. 

In  98  cases  the  fistula  was  completely  closed  on  discharge  of  the 
patient  from  the  hospital;  in  fact  it  has  been  my  practice  to  try  to 
keep  the  patient  in  the  hospital  until  the  fistula  closed.  In  39  cases 
the  fistula  was  open  when  the  patient  left  the  hospital,  but  in  31  of 
these  cases  it  has  since  closed.  In  eight  cases  the  fistula  is  still  open, 
but  four  are  recently  operated  cases. 

In  the  majority  of  cases  the  condition  of  the  patients  were  so  good 
that  they  were  allowed  to  go  home  without  being  catheterized  after 
the  operation,  and  the  subsequent  history  shows  excellent  final  results 
in  all  these  cases.  Two  cases  with  vesical  contracture  and  cystitis 
left  without  our  consent  on  the  14th  and  22d  days  without  having 
been  catheterized,  and  in  both  of  these  cases  the  ultimate  results  have 
not  been  satisfactory  (46,  51). 


102 


Hugh  II.  Young. 


In  59  cases  record  has  been  kept  of  the  finding  witli  a  catlieter 
passed  immediately  before  departure  of  the  patient,  as  follows : 
0  cc.  residual  urine    34   Cases. 


10  ' 

20  ' 

30  ' 

40  ' 

50  ' 

75  ' 

100  • 

110  ' 

150  ' 

200  ' 

2  " 

1  " 

1  " 

1 

1  " 

1  " 

As  remarked  above,  when  we  consider  the  number  of  patients  who 
led  catheter  lives  and  the  frequent  presence  of  extreme  vesical  distention 
it  is  indeed  remarkable  that  there  were  only  12  cases  in  which  40  cc. 
or  more  residual  urine  was  found  on  discharge,  the  examination  gener- 
ally occurring  within  two  or  three  weeks  after  the  operation.  These 
cases  demonstrate  well  the  wonderful  power  the  bladder  has  to  resume 
its  normal  functions  when  obstruction  is  removed  even  though  it  may 
have  been  dilated  to  three  or  four  times  its  normal  capacity,  markedly 
altered  by  inflammation,  the  formation  of  diverticula,  and  the  pres- 
ence of  calculi  and  although  it  had  been  evacuated  only  by  catheter 
for  many  years. 

In  order  that  we  may  arrive  at  some  conclusion  as  to  the  cause  of 
residual  urine  in  the  12  cases  in  which  40  cc.  or  more  was  present, 
and  the  subsequent  course  of  these  cases  I  vrill  give  each  in  brief 
detail. 

Case  I  (17). — 40  cc.  R.  V.  on  discharge.  Over  distention  of  the  bladder 
with  incontinence.  Catheterization  for  two  weeks.  Residual  urine  500  cc, 
small  prostate  with  small  globular  pedunculated  median  lobe.  Total 
weight  15-G.  Microscopically,  chronic  prostatitis.  On  discharge  from  the 
hospit:al  on  the  22d  day  voided  urine  at  intervals  of  four  hours,  fistula 
closed,  condition  excellent.  Report  31  months  after  operation.  Urination 
free,  five  times  during  the  day  and  twice  at  night,  often  a  pint  at  a  time. 
"  I  am  cured." 

Case  II  (95). — 40  cc.  R.  U.  on  discharge.  Catheter  life  for  two  years, 
bladder  capacity  600  cc.  Moderate  enlargement  of  lateral  and  median 
lobes.  Weight  of  prostate  20-G.  Fistula  closed  15th  day.  Discharged 
20th  day  with  urination  normal  at  intervals  of  five  hours.  Report  12 
months  later.  "  Perfectly  cured.  Void  urine  naturally  and  only  rarely 
get  up  at  night." 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  103 

Case  III  (48). — 40  cc.  R.  U.  on  discharge.  When  admitted  urination 
was  every  15  minutes  with  great  pain.  Bladder  irritable,  small,  several 
calculi  present.  Prostate  moderately  enlarged.  The  lateral  lobes  were 
removed,  but  the  median  portion  was  not.  The  fistula  closed  on  the 
27th  day,  patient  discharged  on  the  34th  day  voiding  naturally  at  intervals 
of  five  hours.  R.  U.  40  cc.  B.  C.  210  cc.  Report  20  months  after  operation. 
"In  perfect  health;  urination  natural;  retain  urine  from  three  to  five 
hours." 

Case  IV  (114). — 40  cc.  R.  U.  on  discharge.  When  admitted  catheter- 
ization was  necessary  every  six  hours.  Considerable  enlargement  of 
prostate.  A  large  median  lobe  and  a  large  calculus  seen  with  the  cysto- 
scope.  Perineal  prostatectomy.  Removal  of  three  large  lobes  weighing 
G-80.  A  very  careful  search  was  made  for  the  calculus  but  it  could  not  be 
found.  Thinking  that  the  cystoscopic  examination  was  erroneous  the 
wound  was  closed.  The  convalescence  was  very  satisfactory;  the  patient 
was  discharged  on  the  14th  day,  no  stone  could  be  detected  with  a  silver 
catheter.  The  bladder  capacity  was  230  cc,  R.  U.  40  cc.  Cystoscopy  would 
not  be  permitted.  Six  months  later  the  patient  returned  complaining 
of  pain,  cystoscopy  showed  a  large  calculus  which  was  removed  by  supra- 
pubic route  three  weeks  ago.  At  the  prostate  orifice  was  a  small  fold  of 
mucous  membrane  in  the  median  portion. 

Case  V  (103). — 55  cc.  R.  U.  on  discharge.  Catheterization  required  for 
three  months.  A  slight  enlargement  of  the  prostate  was  present.  Three 
small  lobes  were  removed  weighing  G-15.  Discharged  on  the  34th  day, 
voiding  urine  at  intervals  of  three  hours.  Report  11  months  later.  "  I 
am  cured.    Void  naturally,  once  during  the  night,  15  ounces  at  a  time." 

Case  VI  (45). — 50  cc.  R.  U.  on  discharge.  Complete  retention  of 
urine  for  three  weeks  before  admission.  Moderate  enlargement  of  prostate 
with  small  median  bar,  four  vesical  calculi,  which  were  removed  at 
operation  along  with  a  small  median  bar  and  small  lateral  lobes.  Dis- 
charged on  the  21st  day  in  good  condition,  voiding  urine  at  intervals  of 
four  hours.  Report  by  letter  15  months  later.  "  During  the  night  I  can 
sleep  for  four  hours  without  urinating,  but  during  the  day  I  suffer  pain 
and  void  very  frequently,  and  have  a  feeling  as  if  a  gravel  was  trying 
to  pass." 

Case  VII  (41). — 40  cc.  R.  U.  on  discharge.  Catheter  life  three  months. 
Residual  urine  500  to  800  cc.  Small  median  lobe  and  moderate  lateral 
lobes  removed.  Fistula  closed  in  10  days,  discharged  in  24  days,  urination 
normal,  at  intervals  of  four  hours.  Residual  urine  40  cc.  Bladder  capacity 
300  cc.  Report  22  months  after  operation — letter.  "  I  am  cured.  I  void 
three  times  during  the  day  and  once  at  night  without  difficulty  or  pain." 

EemarJiS. — A  review  of  the  seven  cases  above  in  which  the  residual 
urine  on  discharge  was  from  -iO  to  55  cc.  shows  excellent  ultimate 


104  Hugh  E.  Young. 

results  in  all  but  two  cases.  In  case  lA'  the  failure  to  remove  the  cal- 
culus was  apparently  responsible  for  the  residual  urine,  frequency 
of  urination,  and  pain.,  In  case  YI  the  present  symptoms  point  to 
stone  in  the  bladder,  perhaps  a  recurrence  since  the  operation,  but 
possibly  due  to  the  failure  to  remove  all  the  stones  at  operation.  The 
fact  that  the  patient  is  able  to  retain  urine  for  four  hours  during  the 
night  and  voids  without  difficulty  seems  to  show  that  the  obstruction 
has  been  completely  removed. 

Five  cases  in  which  the  residual  was  more  than  55  cc. : 

Case  I  (107). — 75  cc.  R.  U.  on  discharge.  Dribbling  of  urine  for  one  year. 
Over  distended  bladder  with  1100  cc.  residual  urine.  Removal  of  moderate 
enlargement  of  median  and  lateral  lobes.  Discharged  from  hospital  on  the 
40th  day,  voiding  urine  freely  at  intervals  of  five  hours.  The  fistula  did 
not  close.  Report  two  months  after  the  operation.  "  The  fistula  is  present. 
Urine  is  voided  naturally  but  with  little  force,  three  times  during  the 
day  and  four  times  at  night.  The  catheter  is  not  necessary."  The  patient 
was  killed  in  an  accident  10  months  after  operation. 

Case  II  (37). — 100  cc.  R.  U.  on  discharge.  Prostatic  trouble  12  years. 
Multiple  vesical  diverticula,  small  median  lobe.  180  cc.  residual  urine,  con- 
tracted bladder.  Three  very  small  lobes  were  removed.  The  patient 
improved  rapidly  and  was  discharged  on  the  18th  day  voiding  urine  at 
intervals  of  three  and  one-half  hours,  but  the  catheter  showed  100  cc. 
residual  urine.  On  examination  23  months  later  30  cc.  residual  urine 
was  obtained  by  catheter.  The  cystoscope  showed  a  small  median  fold  and 
the  diverticula  still  present  but  smaller  than  before  operation.  TTie  bladder 
was  contracted,  holding  only  150  cc.  Under  treatment  it  was  dilated  up 
to  325  cc.  and  after  a  month's  treatment,  patient  voided  urine  twice  at 
night  and  four  times  during  the  day. 

Case  III  (64). — 110  cc.  R.  U.  on  discharge.  Complete  retention  of  urine, 
over  distended  bladder,  capacity  800  cc.  Cj'stoscope  showed  a  slight  median 
bar,  but  at  operation  only  the  moderately  enlarged  lateral  lobes  were  re- 
moved. The  fistula  closed  on  the  10th  day  and  the  patient  was  discharged 
on  the  16th  day,  voiding  urine  freely  at  intervals  of  four  hours  during  the 
day  and  seven  hours  at  night.  R.  U.,  110  cc.  B.  C,  310  cc,  no  discomfort. 
Report  18  months  after  operation.  "  Urination  normal,  three  times  during 
the  day  and  twice  at  night,  but  I  drink  much  water.  Consider  myself 
completely  cured." 

Case  IV  (126). — 150  cc.  R.  U.  on  discharge.  Over  distended  bladder. 
R.  U.  940  cc.  Cystoscope  showed  a  slight  median  bar  which  was  not 
removed  at  operation.  Moderately  enlarged  lateral  lobes  removed.  Rapid 
convalescence.  Fistula  closed  16th  day,  discharged  21st,  voiding  urine 
freely  at  intervals  of  five  hours.  The  catheter  showed  150  cc.  residual 
urine.    Report  four  months  later.    Has  improved  steadily.     Urination  four 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  105 

times  during  the  day,  none  at  night,  micturition  normal,  considers  himself 
entirely  cured.    The  catheter  shows  150  cc.  residual  urine. 

Case  V  (50).— 200  cc.  R.  U.  on  discharge.  Over  distended  bladder,  1100 
cc.  R.  U.  Cystoscope  showed  small  median  bar,  and  a  prominent  anteriorly 
projecting  left  lateral  lobe.  At  operation  the  lateral  lobes  were  removed, 
but  the  median  bar  was  not.  The  patient  convalesced  well  and  on 
discharge  from  the  hospital  on  the  37th  day  voided  urine  at  intervals  of 
five  hours.  The  catheter  showed  200  cc.  R.  U.  Five  months  later  the 
patient  returned,  the  catheter  withdrew  400  cc.  residual  urine  and  the 
cystoscope  showed  a  small  median  bar.  A  Bottini  operation  was  performed, 
two  cuts  being  made.  Six  weeks  later  a  catheter  found  250  cc.  R.  U.  and 
B.  C.  740  cc.  with  poor  tonicity.  Letter  one  year  after  Bottini  operation. 
"  Urination  is  free  and  satisfactory.  I  void  12  times  during  the  day  and 
six  times  at  night,  and  from  one-quarter  to  three-quarters  of  a  pint  at  a 
time.     The  result  of  the  operation  is  entirely  satisfactory." 

The  following  two  cases  showed  residual  urine  soon  after  discharge 
from  hospital,  and  are  therefore  given  here : 

Case  VI  (42). — Catheter  life  for  three  years.  Bladder  large,  tonicity 
good,  catheter  used  four  times  daily.  Cystoscope  showed  a  small  round 
median  lobe  which  was  removed  at  operation  and  was  1  cm.  in  diameter. 
Small  lateral  lobes  were  also  remoyed.  The  patient  voided  urine  naturally 
but  frequently  and  with  difficulty  after  the  operation,  and  examination 
three  months  later  showed  500  cc.  residual  urine,  and  a  small  rounded 
median  bar.  A  second  operation  was  performed  one  year  after  the  first 
and  a  tear  was  made  into  the  rectum.  A  small  median  bar  1x1x2  cm. 
in  diameter  was  removed.  The  rectal  wound  broke  down  and  a  recto- 
urethral  fistula  still  persists,  but  the  perineal  fistula  is  closed  and 
frequently  no  urine  passes  into  the  rectum  and  no  feces  into  the  urethra. 
Urine  is  voided  without  difficuty  at  intervals  of  six  hours  during  the  day 
and  he  does  not  have  to  urinate  during  the  night.  He  is  free  from  pain 
and  he  suffers  so  little  discomfort  that  he  has  refused  to  have  anything 
done  to  the  recto-urethral  fistula  which  is  apparently  steadily  diminishing 
in  size. 

Case  VII  (44). — Very  frequent  urination,  over  distended  bladder,  1000  cc. 
residual  urine,  small  median  bar.  At  operation  slightly  enlarged  lateral 
lobes  and  a  small  suburethral  median  lobe  were  removed.  The  patient 
convalesced  well  and  was  discharged  on  the  25th  day,  but  urination  was 
quite  frequent  and  examination  several  months  later  showed  200  cc. 
residual  urine,  and  with  the  cystoscope  a  small  but  definitely  round  median 
bar  was  seen. 

May  19,  1906. —  (21  months  after  operation.)  The  catheter  withdraws 
400  cc.  R.  U.  and  the  cystoscope  shows  a  small  rounded  median  lobe.  Urine 
is  voided  without  much  difficulty  at  intervals  of  two  hours.  He  catheterizes 
himself  at  bed  time  and  sleeps  all  night.  He  is  so  comfortable  that  he 
refuses  further  operation.  This  is  the  only  patient  who  uses  a  catheter. 
Vol.  XIV.— 8. 


106  Hugh  H.  Young. 

The  following  case  in  which  the  ohstruction  was  not  completely 
removed,  until  a  second  operation  had  been  performed  one  week  after 
the  first  operation  should  be  included  here: 

Case  VIII  (141). — Catheter  life  for  two  years.  Small  prostate  with 
globular  median  lobe.  Removal  of  small  lateral  lobes,  and  a  pedunculated 
median  lobe  through  the  urethra.  Examination  with  the  finger  showed  no 
remaining  obstruction,  but  an  unusually  strong  or  firm  sphincter.  It  was 
thought  unnecessary  to  do  more  than  to  dilate  this.  After  removal  of  the 
tubes  urination  was  difficult  and  painful  and  the  catheter  showed  500  cc. 
residual  urine.  One  week  after  the  first  operation  the  wound  was  broken 
open,  and  the  median  portion  of  the  prostate  along  with  a  piece  of  the 
vesical  sphincter  and  the  small  capsule  left  by  the  median  lobe  was 
excised  leaving  a  large  opening  at  the  vesical  orifice.  The  edges  of  the 
wound  were  reunited,  the  tubes  were  withdrawn  on  the  next  day.  The 
convalescence  was  rapid  and  in  a  few  days  the  urine  began  to  fiow  through 
the  anterior  urethra,  the  perineal  fistula  closed  in  12  days  (20  days  after 
the  first  operation)  and  the  patient  was  discharged  on  the  22d  day  after 
the  first  operation  voiding  urine  freely  at  intervals  of  four  hours  and  the 
catheter  showed  no  residual  urine. 

Remarl-. — In  Cases  II  and  III  the  residual  of  100  cc,  which  was 
present  on  discharge  from  the  hospital,  has  since  disappeared,  one 
case  being  entirely  well  and  the  other  case  (II)  suffering  only  from 
contracture  of  the  bladder  and  diverticula.  Cases  VI  and  VIII  are 
apparently  identical  in  that  the  removal  of  small  globular  median 
lobe  was  not  sufficient  to  provide  free  evacuation  of  urine,  and  it  was 
necessary  at  secondary  operations  to  excise  the  median  portion  of  the 
prostate  along  with  that  part  of  the  vesical  sphincter.  The  splendid 
result  obtained  in  Case  VIII  shows  the  advisability  of  doing  the  second 
operation  without  delay.  In  both  of  these  cases  the  entire  prostate 
was  very  small  and  of  the  inflammatory  sclerotic  variety  (the  kind 
which  Albarran  declares  are  unsuitable  for  prostatectomy  by  the 
perineal  route),  but  the  results  obtained  in  these  two  cases  show  con- 
clusively that  if  the  median  portion  of  the  prostate  beneath  a  peduncu- 
lated lobe  is  excised  in  these  cases  and  a  free  opening  provided,  excel- 
lent results  can  be  obtained. 

In  Cases  I,  IV,  V,  and  VII,  the  bladder  was  markedly  overdis- 
tended,  and  atonic  before  operation,  and  this  probably  had  a  good  deal 
to  do  with  the  incomplete  evacuation  of  urine,  but  in  the  last  three 
cases  the  median  portion  of  the  prostate,  which  was  shown  by  the  cysto- 
scope  to  be  distinctly,  although  slightly,  enlarged,  was  not  removed. 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  107 

and  I  feel  certain  that  had  this  been  done  very  thoroughly  there  would 
be  no  residual  urine  present.  In  ordinary  cases  (where  the  bladder  is 
not  atonic  and  greatly  distended  before  operation)  the  small  amount 
of  obstruction  which  these  cases  present,  would  not,  I  believe,  be 
sufficient  to  prevent  complete  evacuation  of  urine.  I  confess  that 
an  incomplete  operation  has  been  responsible  for  the  imperfect  re- 
sults shown  in  the  five  cases  mentioned  above  (Cases  IV,  V,  VI,  VII, 
and  A^II).  In  all  other  cases  the  operation  has  been  entirely  satis- 
factory in  that  the  obstruction  has  been  completely  removed  and  free 
urination  established. 

In  the  majority  of  cases  the  interval  between  urinations  was  four 
hours  or  more  on  discharge  from  the  hospital.  In  a  number  of  in- 
stances it  was  more  frequent  than  normal  owing  to  cystitis  and  con- 
tracture of  the  bladder.  This  was  particularly  true  in  cases  where 
calculi  had  been  present,  where  the  bladder  had  been  drained  for  a 
long  time  through  a  retained  urethral  catheter,  or  by  suprapubic 
fistula,     (These  cases  will  be  discussed  later.) 

Voluntary  control  of  urination. — As  remarked  before,  one  of  the 
most  remarkable  results  of  the  operation  is  the  rapidity  in  which 
voluntary  control  with  interval  urination  is  established,  in  many 
cases  coming  on  immediately  after  removal  of  the  drainage  tubes. 
At  first  the  sphincter  is  usually  a  little  weak  and  a  few  drops  of  urine 
may  escape  when  the  patient  suddenly  changes  his  position,  coughs, 
or  sneezes,  but  in  all  but  a  small  number  of  cases  complete  control 
was  established  before  the  patient  left  the  hospital.  In  six  cases  there 
was  for  a  short  time  a  slight  incontinence  when  the  patient  was  on 
his  feet.  This  occurred  only  occasionally,  however,  and  there  was  no 
incontinence  during  the  night.  In  only  three  cases  has  this  slight 
occasional  diurnal  incontinence  persisted.  These  cases  will  be  referred 
to  at  length  in  discussing  the  ultimate  results. 

Suprapubic  fistulce  were  present  in  eight  cases  (96,  13,  16,  9,  69, 
63,  131,  70),  but  in  only  two  cases  required  a  second  operation  to 
effect  a  closure.  In  both  of  these  cases  (16,  63)  the  fistula  was  sur- 
rounded by  considerable  scar  tissue  which  was  excised  at  the  second 
operation. 

Where  suprapubic  fistulte  are  present  I  usually  put  only  one  catheter 
in  the  perineal  wound  and  another  in  the  suprapubic.  The  continu- 
ous irrigation  being  maintained  through  one  and  out  the  other.  The 
Vol.  XIV.— 9. 


108  Hugh  H.  Young. 

perineal  tube  is  removed  on  the  next  day,  but  the  suprapubic  drainage 
is  maintained  until  the  perineal  wound  is  completely  healed,  when 
the  tube  is  removed  and  the  fistula  thoroughly  curetted.  Prompt 
closure  has  been  thus  effected  in  all  but  the  two  cases  mentioned 
above.  The  great  objection  to  suprapubic  fistulse  is  that  the 
bladder  is  usually  contracted,  and  often  never  regains  its  normal 
capacity. 

G.    THE  CONDITION  OF  PATIENTS  AFTEE  LEAVING  THE  HOSPITAL. 

At  intervals  of  six  months  (and  sometimes  less)  I  have  sent  circu- 
lar letters  to  all  perineal  prostatectomy  cases  with  a  set  of  questions 
to  be  answered.  In  these*  the  patient  was  asked  whether  the  perineal 
fistula  was  closed,  whether  a  catheter  was  used,  how  often  urine  was 
passed  by  day  and  by  night,  the  amount  voided  at  one  time,  as  to  the 
presence  of  pain,  the  return  of  erections,  whether  sexual  intercourse 
was  possible  and  in  what  way  it  differed  from  condition  previous  to 
operation,  as  to  complications,  treatment,  general  health,  gain  in 
weight,  and  finally  whether  they  considered  themselves  cured. 

I  have  been  remarkably  successful  in  keeping  track  of  these  cases, 
and  up  to  ISTovember  30,  1905,  failed  to  hear  each  time  from  but  one 
case.  This  patient  (35)  who  was  operated  upon  March  22,  1904, 
replied  on  May  22,  1904,  saying  that  the  wound  was  closed,  that  he 
considered  himself  cured,  and  that  his  general  health  was  fairly  good. 
I  have  since  written  him,  his  physician,  and  his  wife  several  letters 
but  have  not  received  any  answer. 

On  May  5,  1906,  the  last  circular  letter  was  despatched,  and  replies 
have  been  received  from  all  but  six  cases  (but  these  had  answered 
November  30,  1905).' 

*  October  1,  1906. — Just  before  the  correction  of  the  page  proof  circular 
letters  were  again  sent  to  the  50  cases  which  had  been  operated  during  the 
year  previous  to  June,  1906.  Replies  have  been  received  from  all  but  seven 
of  these,  and  their  answers  have  been  attached  to  their  histories  reported 
In  the  appendix.  All  of  the  seven  cases  who  failed  to  reply  had  been  fol- 
lowed for  several  months  after  the  operation,  and  I  am  confident  that 
they  are  all  in  good  condition.  A  review  of  the  final  answers  of  these  50 
cases  shows  a  continued  improvement  in  their  condition.  In  many  of 
the  recent  cases  in  which  the  sexual  powers  had  not  returned  the  patients 
now  report  a  return  of  erections.  We  still  have  to  record  only  one  death 
in  the  50  cases  operated  during  that  year,  and  the  functional  results  ob- 
tained fully  bear  out  the  statements  made  previously  in  other  parts  of 
this  article. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  109 

Fifteen  patients  have  died  since  leaving  the  hospital.  The  earliest 
case  is  that  of  No.  (73)  who  died  one  month  after  the  operation  from 
"  cerebral  hemorrhage."  The  immediate  result  in  this  case  was  ex- 
cellent and  the  operation  apparently  had  nothing  to  do  with  his  death. 
Two  patients  committed  suicide  four  and  six  months  after  operation 
(cases  51,  55).  Two  patients  (6,  9)  died  five  months  after  the  opera- 
tion of  intercurrent  diseases.  Both  had  been  completely  cured  by  the 
operation.  One  patient  (case  107)  died  seven  months  after  the  opera- 
tion in  a  runaway  accident,  and  one  (49)  died  four  months  after 
operation,  of  apoplexy. 

One  patient  (case  5)  died  eight  months  after  the  operation  of  angina 
pectoris.  He  had  been  completely  cured  by  the  operation.  Three 
patients  (31,  24,  33)  died  one  year  after  the  operation,  one  of  pneu- 
monia, one  of  uremia,  and  one  of  causes  which  cannot  be  ascertained. 
The  first  patient  had  been  completely  cured  by  the  operation,  the  sec- 
ond and  third  cases  had  suffered  severely  from  severe  cystitis,  con- 
tracture of  the  bladder,  and  autopsy  on  one  showed  double  pyone- 
phrosis. Two  cases  died  23  months  after  the  operation,  one  an  acci- 
dental death  while  exploring  in  Africa,  and  the  second  of  unknown 
cause.     Both  had  been  cured  by  the  operation. 

One  patient  (4)  died  3  months  after  the  operation  of  "  catarrh  of 
the  stomach."     He  had  had  no  urinary  trouble  since  operation. 

The  only  patient  among  these  15,  who  have  died  since  leaving  the 
hospital,  in  whom  the  obstruction  to  urination  had  not  been  completely 
removed  was  that  of  case  50,  who  died  20  months  after  the  operation 
suddenly  of  unknown  cause.  I  received  a  letter  from  him  three 
months  before  his  death  in  which  he  said  that  the  result  of  the  opera- 
tion had  been  entirely  satisfactory,  but  at  an  examination  one  year 
before  I  had  found  300  cc.  residual  urine. 

A  review  of  these  15  cases  shows  that  the  operation  was  not  re- 
sponsible for  the  death  in  a  single  case.  In  four  cases  there  had  been 
evidence  of  impairment  of  the  kidneys,  one  had  definite  nephritis 
and  the  autopsy  in  one  case  showed  pyonephrosis.  The  other  patients 
met  accidental  deaths  (three)  or  died  of  intercurrent  diseases  in  no 
way  connected  with  the  urinary  tract.  Six  of  these  patients  were  in 
splendid  condition  before  and  after  operation,  and  in  the  other  cases 
the  general  condition  was  not  nearly  so  bad  as  in  many  of  the  patients 
who  are  still  living. 


110  Hugli  H.  Young. 

The  number  of  months  elapsed  between  operation  and  last  report 
are  as  follows : 

1  months 0  Cases.  19  months 2   Cases. 

2  "         4       "  20         "  5       " 

3  "         2       "  21         "  3       " 

4  "         4       "  22         "  3 


5  "  7  "  24  "  6  " 

6  "  3  "  25  " 1  " 

7  "  4  "  26  "  3  " 

8  "  3  "  27  "  2  " 

9  "  3  "  28  "  2  " 

10  "  3  "  29  "  1  " 

11  "  9  "  30  "  4  " 

12  "  14  "  31  "  2  " 

13  "  7  "  32  "       • 1 

14  "  7  "  36  "  4  " 

15  "  5  "  38  "  2 

18  "  7  "  42  "  1 

H.    COXTRACTURE  OF  THE  BLADDER  BEFORE  AND  AFTER  OPERATION. 

In  50%  of  the  cases  the  capacity  of  the  bladder  before  operation 
was  distinctly  contracted,  i.  e.,  less  than  400  cc.  In  52  cases  (37%,), 
the  contracture  was  marked,  and  the  capacit}^  of  the  bladder  between 
50  and  300  cc.  Seventeen  of  these  cases  w^ere  complicated  with  stone 
in  the  bladder,  three  had  previously  had  calculus,  two  had  calculi 
after  the  operation,  and  30  were  not  associated  with  calculi. 

The  following  table  shows  the  capacity  of  the  bladder  and  residual 
urine  in  these  30  cases  in  which  no  calculi  were  present: 

Retention  Incomplete. 


B.C. 

Ke 

tention  Complete. 
B.C. 

0   Cases. 

0   Cases. 

1       " 

0       " 

2       " 

0       " 

7       " 
11       " 

0       " 
2       " 

7       " 

0       " 

R.  TJ. 

50  CC 15  Cases. 

100     "        5  " 

150     "        2  " 

200     "        2  " 

250     "        5  " 

300     "        0  " 

Among  25  cases  in  which  calculi  were  present  the  bladder  capacity 
was  between  50  and  250  cc.  in  18  cases  as  follows : 

50  cc 2  Cases. 

100     "        4       " 

150     "        4       " 

200     "        3       " 

250     "        ■..  5       " 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  Ill 

In  eight  eases  in  which  the  urine  escaped  through  suprapubic 
fistulge  the  bladder  was  contracted  in  every  case. 

A  review  of  these  cases  shows  that  where  calculi  are  present  the 
bladder  is  apt  to  becojne  contracted  in  the  vast  majority  of  cases, 
there  being  only  three  in  our  series  in  which  it  was  as  large  as  normal 
(500  cc).  In  these  cases  the  contracture  is  undoubtedly  due  to  the 
frequency  of  urination  produced  by  the  presence  of  calculi. 

In  cases  where  suprapubic  drainage  has  been  provided  contracture 
almost  always  results  owing  to  the  removal  of  all  intravesical  pres- 
sure. But  in  those  cases  in  which  neither  of  these  conditions  are 
present  the  explanation  is  not  so  easy.  In  some  case  severe  cystitis, 
pericystitis,  vesical  ulcers,  and  diverticula  are  responsible  for  the 
condition,  but  in  many  instances  none  of  these  etiological  factors 
have  been  present.  In  such  cases  I  believe  the  contracture  is  due  to 
a  thickening  of  the  muscular  coats  of  the  bladder  brought  about  by 
efforts  to  force  the  urine  through  the  narrowed  orifice.  This  condi- 
tion of  contracture  apparently  persists  as  long  as  the  retention  of  urine 
is  not  complete  and  the  residual  urine  is  not  very  large,  as  a  review 
of  my  cases  shows  no  case  with  contracture  of  the  bladder  and  com- 
plete retention  of  urine  except  those  in  which  calculi  were  present  or 
the  bladder  had  become  contracted  from  long  drainage  through  a  su- 
prapubic or  a  urethral  catheter.  Contracture  of  the  bladder  appears 
therefore  to  be  the  first  change  which  occurs  in  the  viscus  as  a  result 
of  prostatic  obstruction.  Later,  residual  urine  begins  to  appear  and 
gradually  increases  in  amount  until  it  approaches  that  of  the  vesical 
capacity.  When  the  residual  urine  becomes  very  large  the  bladder 
apparently  begins  to  dilate  in  a  certain  number  of  the  cases,  and  as 
remarked  above,  is  almost  always  large  in  uncomplicated  cases  when 
the  retention  of  urine  is  complete.  The  formation  of  trabeculse, 
pouches,  and  diverticula  occur  simultaneously  with  the  thickening  of 
the  muscular  coats  and  the  increase  in  intravesical  tension,  and  in  a 
few  cases  diverticula  may  form  an  important  complication,  as  shown  in 
cases   (30,  143,  82,  37). 

A  study  of  the  cases  in  which  frequency  of  urination  has  been  present 
after  the  operation  shows  that  it  is  almost  always  due  to  previous 
contracture  of  the  bladder. 

In  30  cases  urination  was  more  frequent  than  usual  at  the  time  of 
discharge  from  the  hospital,  varying  from  one  to  three  hours,  and  in 
one  case  being  every  half  hour,  and  all  of  these  cases  were  character- 


112  Hugh  H.  Young. 

ized  by  contracture  of  the  bladder  before  operation  and  in  16  calculi 
had  been  present.  The  treatment  adopted  in  these  cases  was  simply 
to  have  the  patient  drink  water  in  great  abundance  and  retain  urine 
as  long  as  possible  in  the  bladder  to  dilate  the  bladder  by  hydraulic 
pressure,  given  with  or  without  a  catheter.  The  results  have  been 
remarkably  good  and  in  many  instances  where  the  bladder  was  con- 
siderably contracted  before  and  immediately  after  operation,  the 
capacity  has  gradually  increased  until  now  the  patient  voids  as  much 
as  500  cc.  at  one  time. 

A  careful  study  of  the  ultimate  results  of  these  145  cases  shows 
only  23  in  which  urination  may  be  said  to  be  too  frequent,  and  in  all 
but  four  of  these  cases  more  or  less  marked  contracture  of  the  bladder 
was  present  before  operation.  One  case  with  a  bladder  capacity  of 
500  cc.  before  operation  and  complete  retention  of  urine  voids,  now 
five  months  after  the  operation,  at  intervals  of  three  hours,  and  300 
cc.  in  amount  (125).  The  other  three  cases  were  those  in  which 
the  obstruction  was  not  completely  removed  (44,  50,  51)  and  will 
be  given  in  full  later  on. 

Eeports  from  the  remaining  19  cases  show  that  the  amount  of  urine 
voided  at  a  time  is  about  60  cc.  in  two  cases,  "  small "  in  four  cases, 
125  cc.  in  one  case,  150  cc.  in  two  cases,  200  cc.  in  one  case,  250  cc. 
in  two  cases,  300  cc.  in  four  cases,  500  cc.  in  one  case,  "  abundant " 
one  case. 

The  interval  between  urination  is  two  hours  in  four  cases,  two  and 
a  half  hours  in  one  case,  three  hours  in  eight  cases,  one  hour  during 
the  day  and  four  hours  at  night  one  case,  two  and  a  half  hours  during 
the  day  and  five  hours  at  night  in  two  cases. 

In  the  three  cases  mentioned  above  in  which  the  obstruction  was 
not  removed  the  interval  was  one  hour  in  two  cases  and  "very  fre- 
quent "  in  one. 

A  review  of  these  cases  shows  conclusively  that  the  most  common 
cause  of  frequency  of  urination  after  prostatectomy,  when  the  ob- 
struction has  been  completely  removed,  is  contracture  of  the  bladder. 
In  cases  where  poh-uria  is  not  present  and  the  patient  voids  about  1500 
cc.  of  urine  a  day,  a  bladder  capacity  of  300  cc.  causes  no  incon- 
venience, and  the  patient  does  not  have  to  void  more  than  five  or  six 
times  a  day.  But  in  most  of  these  old  men  polyuria  is  present  in 
marked  degree,  and  when  the  bladder  is  at  all  contracted  urination 
is  necessarily  more  frequent  than  normal.     A.  peculiar  feature  in  re- 


study  of  IJ^B  Cases  of  'Perineal  Prostatectomy.  113 

gard  to  these  polyurias  is  that  more  urine  is  secreted  at  night,  when 
the  patient  is  supine,  than  during  the  day,  and  this  accounts  for  the 
frequency  with  which  some  of  these  patients  have  to  arise  at  night  to 
urinate.  In  one  of  my  cases  60  to  80  ounces  of  urine  was  secreted 
during  the  night  and  only  10  ounces  during  the  day.  In  such  a  case 
nocturnal  frequency  of  urination  is  necessary  although  the  bladder 
may  be  fairly  large. 

In  conclusion  I  may  say  that  in  only  those  cases  characterized  by 
contracture  of  the  bladder  is  the  patient  disturbed  at  all  by  frequency 
of  urination  (barring  the  three  cases  of  incomplete  prostatectomy 
mentioned  above). 

I.    ULTIMATE  RESULTS. 

Mortality. 

There  have  been  seven  deaths  following  the  operation. 

In  none  of  the  cases  was  the  death  directly  in  consequence  of  the 
operation,  as  shown  by  the  fact  that  one  occurred  during  the  fifth 
week,  two  during  the  fourth  week,  three  during  the  third  week,  and 
one  during  the  second  week  after  the  operation. 

The  cause  of  death  was  as  follows :  Pulmonary  thrombosis,  one 
case ;  hypostatic  congestion  of  the  lungs,  two  cases ;  double  pneumonia, 
one  case;  pyonephrosis  and  uremia,  two  cases;  secondary  hemorrhage 
from  a  vesical  ulcer  on  eighth  day  after  operation,  one  case. 

All  but  one  of  the  patients  were  in  weak  condition  before  the  opera- 
tion, and  two  were  over  80  years  of  age,  one  being  87  years.  Two 
were  markedly  uremic,  going  down  rapidly,  and  were  operated  on  as  a 
last  resort.    The  seven  cases  were  briefly  as  follows : 

Case  I  (21). — Age  73,  admitted  November  20,  1903.  Examination  shows 
a  diastolic  murmur  and  a  blurring  of  the  heart  sounds  in  the  aortic  area. 
The  prostate  is  only  slightly  hypertrophied  and  the  cystoscope  shows  a 
small  median  lobe. 

Operation,  Novem'ber  20. — Removal  of  median  and  lateral  lobes.  The 
patient  reacted  well,  pulse  88  at  the  end,  temperature  99  on  the  following 
night.  In  a  few  days  the  patient  was  out  of  bed  and  walking  about  the 
ward. 

13th  day. — Patient  in  excellent  condition,  voiding  urine  through  urethra, 
almost  ready  to  leave  hospital. 

December  3,  1903. — The  patient  has  become  constipated  and  a  soap-suds 
enema  is  ordered.  The  enema  caused  considerable  tenesmus  and  im- 
mediately afterward  the  patient  vomited  and  suddenly  collapsed,  dying 
within  five  minutes. 

Autopsy. — There   is   a  firm   organized   clot  with   fresh   clot  built   on   it 


114  Hugh  H.  Young. 

extending  from  the  left  auricle  down  the  inferior  vena  cava.     Condition 
of  bladder  and  wound  excellent. 

Case  II  (23).— Age  81,  admitted  November  14,  1903.  Considerable  gen- 
eral arteriosclerosis  and  intermittent  pulse.  Bladder  greatly  distended 
reaching  two  inches  above  umbilicus.  Catheter  removes  2000  cc.  residual 
urine  without  emptying  the  bladder.  After  four  days,  catheterization 
became  impossible  and  suprapubic  aspiration  was  performed  for  five  days. 

Operation,  November  2Jf,  1903. — Removal  of  lateral  lobes,  a  small  median 
bar  which  was  present  did  not  seem  sufficiently  large  to  warrant  removal. 
The  patient  reacted  well,  but  when  the  tubes  were  removed  the  bladder 
became  distended  and  they  had  to  be  reinserted.  Three  weeks  after  the 
operation  the  patient  became  weak,  hypostatic  congestion  of  the  lungs 
developed  and  on  December  24  he  died  (31st  day). 

Case  III  (52).— Age  65,  admitted  September  20,  1904.  Patient  in  bad 
condition,  frequent  nausea  and  vomiting,  symptoms  of  uremia  of  long 
duration.  Catheterization  impossible,  aspiration  performed.  Later  suc- 
cessful catheterization.  Constant  drainage  of  bladder  with  catheter  for 
10  days.  At  the  end  of  this  time  the  urethra  was  irritable,  catheter  caused 
pain,  the  patient  was  still  uremic  and  nauseated.  Operation  to  supply 
better  drainage  decided  upon. 

September  30. — Removal  of  three  moderately  enlarged  lobes.  Following 
operation  the  uremia,  nausea,  and  vomiting  continued.  The  patient  took 
no  food  and  on  October  13  enterostomy  was  performed  to  supply  nourish- 
ment. The  patient  died  on  the  14th  day.  Autopsy  showed  double  hydro- 
pyonephrosis. 

Case  IV  (65).— 'Age  87,  admitted  December  3,  1904.  Arteries  moderately 
sclerotic  and  heart  enlarged.    Prostate  very  large. 

Operation,  December  7. — Enucleation  of  very  large  lateral  and  median 
lobes.  The  patient  reacted  well,  and  on  December  27  was  in  excellent 
condition  voiding  through  the  anterior  urethra  and  walking  about  the 
ward.  On  the  next  day,  three  weeks  after  the  operation,  his  temperature 
began  to  rise  and  was  associated  with  severe  bronchitis  which  rapidly 
changed  into  pneumonia,  and  the  patient  died  January  1,  24th  day. 

Case  V  (83).-^Age  73.  admitted  April  17,  1905.  Suprapubic  prostat- 
ectomy had  been  performed  four  years  before  by  another  surgeon  and 
patient  was  in  desperate  condition  after  the  operation.  The  lungs  are 
hyperresonant,  the  heart  enlarged  and  several  murmurs  are  present.  The 
prostate  is  considerably  enlarged  and  the  cystoscope  shows  two  calculi. 

Opetation,  April  24. — Removal  of  lateral  lobes;  median  portion  slight 
and  not  removed.  The  patient  reacted  well,  but  on  May  1  had  a  chill 
followed  by  fever,  drowsiness  and  hiccoughing  which  persisted  until  his 
death.  May  14.  Death  from  hypostatic  congestion  of  the  lungs  on  the 
21st  day.    No  autopsy. 

Case  VI  (89). — Age  53,  admitted  August  1,  1904.  Severe  stricture  of 
urethra  and  cystitis  following  gonorrhoea  18  years  ago.  Dilatation  of 
stricture  afforded  no  relief,  the  bladder  was  contracted,  there  were  100  cc. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  115 

residual  urine  present.  The  cystoscope  showed  a  large  vesical  ulcer 
involving  the  entire  trigone  and  a  slight  median  bar.  The  prostate  was 
indurated  but  very  little  enlarged.  The  patient  was  pale,  weak,  despondent. 
Prostatic  massage  and  urethral  dilatations  was  used  intermittently  for  nine 
months  without  benefit  and  finally  it  was  decided  to  perform  urethrotomy 
for  the  stricture  and  at  the  same  time  to  perform  partial  prostatectomy 
and  curette  the  vesical  ulcer.  Four  days  after  the  operation  there  was 
considerable  bleeding,  seemingly  from  the  bladder,  which  was  apparently 
controlled,  but  several  days  later  there  was  more  hemorrhage  and  pain  in 
the  bladder  followed  by  the  passage  of  clots  and  on  May  10  a  suprapubic 
operation  was  performed  and  a  large  clot  evacuated  from  the  bladder  which 
was  then  packed  with  gauze.  The  patient  did  not  improve,  however,  and 
died  the  next  day.    Autopsy  not  allowed. 

Case  VII  (109).— Age  73,  admitted  July  20,  1905.  A  very  weak  sick  old 
man.  The  prostate  is  markedly  enlarged.  The  patient  was  treated  by 
frequent  catheterization  for  four  days,  but  his  condition  grew  steadily 
worse,  fever,  nausea,  and  vomiting  were  present  and  he  was  drowsy  and 
irrational.  Catheter  drainage  did  not  seem  sufficient  and  it  was  thought 
best  to  supply  perineal  drainage  after  removal  of  the  prostate.  The  patient 
stood  the  operation  well,  and  for  a  few  days  seemed  to  improve,  but  he 
soon  showed  evidence  of  uremia  again  and  finally  died  on  August  17  (the 
27th  day  after  the  operation)   of  uremia.     Autopsy  was  not  allowed. 

Although  in  several  of  the  seven  fatal  cases  reported  above  death 
was  in  no  way  caused  by  the  operation,  it  is  necessary  to  include  all 
of  them  in  figuring  the  mortality.* 

*Final  Note  as  to  Mortality,  January  7,  1907. — Just  before  going  to  press 
I  take  the  opportunity  of  bringing  my  statistics  up  to  date,  thus  covering 
the  period  of  six  months  since  the  manuscript  was  finished  and  sent  to  the 
printer.  The  many  apparent  unavoidable  delays  in  the  publication  of  this 
volume  thus  gives  me  an  opportunity  of  adding  many  other  cases.  I  am 
glad  to  report  that  there  have  been  no  other  deaths  or  imperfect  results; 
that  all  the  patients  have  left  the  hospital  well,  and  that  as  a  whole  the 
convalescence  has  become  steadily  better. 

I  have  now  had  185  consecutive  cases  of  perineal  prostatectomy  with 
seven  deaths  as  above  recorded,  a  mortality  of  3.7%.  This  includes  all 
of  the  early  cases,  when  the  operation  was  in  a  developmental  stage  and 
much  less  satisfactory — the  patient  being  confined  to  bed  and  the  drainage 
not  removed  for  much  longer  periods.  It  certainly  does  not  represent  the 
true  mortality.  During  the  past  two  and  one-half  years  there  have  been 
100  cases  with  only  two  deaths,  a  mortality  of  2%.  But  the  most  con- 
vincing evidence  of  the  benignity  of  the  operation  of  conservative  perineal 
prostatectomy  is  the  fact  that  in  the  last  60  consecutive  cases  there  has 
not  been  a  single  death  or  bad  result. 


116  HugTi  H.  Young. 

The  Removal  of  Obstruction. 
There  are  only  four  cases  presenting  evidence  that  the  obstruction 
to  free  urination  has  not  been  completely  removed.  In  three  of  these 
cases  definite  evidence  of  obstruction  with  residual  urine  manifested 
itself,  but  in  only  one  case  did  complete  retention  of  urine  supervene. 
In  the  fourth  case  the  patient  voids  freely  at  normal  intervals  and 
does  not  arise  at  night,  and  was  greatly  surprised  when  150  cc.  resi- 
dual urine  was  obtained.  This  case  (136)  was  one  in  which  the 
bladder  was  greatly  distended  and  atonic,  with  a  residual  urine  of 
940  cc,  and  as  only  five  months  have  elapsed  since  the  operation  it  is 
possible  that  this  residuum  may  eventually  disappear.  The  three 
cases  in  which  definite  obstruction  has  shown  itself  are  as  follows: 

Case  I  (50). — Age  71,  admitted  September  7,  1904.  Difficulty  of  urination 
has  been  present  for  30  years,  and  for  25  years  bas  had  to  arise  10  or 
12  times  at  night  to  urinate.  The  bladder  is  greatly  distended,  the 
catheter  withdraws  1100  cc.  residual  urine  and  the  vesical  tonicity  is  poor. 
The  prostate  is  moderately  bypertrophied  and  the  cystoscope  shows  a  slight 
median  bar.  After  three  weeks  catheterization,  the  amount  of  residual 
urine  was  still  900  cc. 

Operation,  September  21. — Removal  of  the  lateral  lobes,  median  thought 
to  be  too  small  to  warrant  removal.  The  patient  reacted  well  and  was 
discharged  on  the  37th  day,  but  the  catheter  showed  200  cc.  residual  urine. 
Three  months  later  it  had  increased  to  400  cc.  and  the  cystoscope  showed 
a  small  median  bar.  A  Bottini  operation  was  performed  and  six  weeks 
later  only  200  cc.  residual  urine  was  found. 

February  5,  1906. — Letter.  "  Although  I  void  urine  about  a  dozen  times 
during  the  day  and  six  times  at  night,  urination  is  free,  the  amount  voided 
is  sometimes  three-fourths  of  a  pint  at  a  time  and  the  result  of  the 
operation  is  entirely  satisfactory." 

Case  II  (44). — Age  65,  admitted  August  5,  1904.  Difficulty  of  urination 
for  three  years.  On  admission  urination  every  15  minutes  during  the  day 
and  eight  times  at  night.  The  bladder  is  greatly  distended  and  1000  cc. 
residual  urine  are  withdrawn.  The  cystoscope  shows  a  slight  enlargement 
of  the  median  and  lateral  lobes.  On  rectal  examination  the  prostate  is 
only  slightly  enlarged.    Catheterization  three  times  daily  for  two  weeks. 

Operation,  August  18,  1904- — Enucleation  of  two  small  lateral  lobes  each 
in  one  piece  and  a  small  rounded  median  lobe.  Patient  convalesced  well 
and  was  discharged  on  the  25th  day.  Seven  months  after  the  operation 
the  catheter  found  200  cc.  residual  urine.  The  cystoscope  showed  a  slight 
rounded  median  bar.  With  finger  in  rectum  and  cystoscope  in  urethra 
the  median  portion  of  the  prostate  was  no  thicker  than  normal. 

3Iay  19,  1906. — The  patient  voided  100  cc.  and  the  catheter  withdrew  500 


study  of  145  Cases  of  'Perineal  Prostatectomy.  117 

cc.  The  cystoscope  shows  a  small  rounded  median  lobe.  The  patient  uses 
a  catheter  at  bed-time  and  in  the  morning,  but  during  the  day  voids  urine 
naturally  at  intervals  of  two  hours,  and  is  entirely  comfortable.  He 
refuses  further  operation. 

Case  III  (51). — Age  67,  admitted  August  1,  1904.  Difficulty  of  urination 
for  two  years,  considerable  pain,  voiding  at  intervals  of  15  minutes.  The 
prostate  is  small  and  hard.  The  cystoscope  shows  a  small  median  lobe, 
the  residual  urine  is  only  20  cc.  and  the  bladder  irritable  and  contracted 
holding  only  140  cc. 

Operation. — Excision  of  two  small  lateral  lobes  and  a  small  globular 
suburethral  median  lobe.  The  convalescence  was  very  satisfactory,  and 
two  months  later  a  catheter  showed  no  residual  urine  and  a  bladder 
capacity  of  300  cc.  The  urine  was  voided  freely  at  intervals  of  an  hour 
and  the  condition  of  the  patient  was  good. 

May,  1906. — The  patient's  family  report  that  some  time  after  discharge 
the  patient  began  to  suffer  pain,  urination  became  difficult  and  very 
frequent  and  finally  catheterization  was  necessary  for  four  days  when  the 
patient  committed  suicide. 

In  reviewing  these  three  cases  it  is  evident  that  the  obstruction  was 
not  completely  removed  from  the  median  portion  of  the  prostate.  It 
is  interesting  to  note  that  the  prostate  was  of  the  small  sclerotic 
variety,  and  as  remarked  in  an  earlier  chapter  of  this  paper  it  is 
evident  that  in  these  eases  there  is  generally  a  fibrons  ring  at  the  vesical 
neck  which  requires  more  than  removal  of  a  pedunculated  median  lobe 
to  relieve  the  obstruction  completely.  These  three  cases  occurred  dur- 
ing xVugust  and  September,  1904.  It  is  now  my  practice  in  cases 
where  the  prostate  is  of  the  small  fibrous  variety  to  insert  the  index 
finger  through  the  urethra  into  the  bladder  after  the  removal  of  the 
prostatic  lobes,  and,  if  I  find  at  the  vesical  orifice  a  very  tight 
sphincter  or  a  mass  of  tissue  remaining  in  the  median  portion  after 
removal  of  the  intravesical  middle  lobe,  I  expose  the  median  portion 
of  the  prostate  by  dividing  the  lateral  wall  of  the  prostatic  urethra, 
and  then  excise  the  median  portion  of  the  prostate  along  with  the 
mucous  membrane  covering  it.  In  the  several  cases  in  which  this  has 
been  done  the  results  have  been  perfect,  and  it  is  remarkable  to  note 
that  voluntary  urination  with  perfect  control  was  established  within  a 
few  days  after  the  operation.  An  examination  of  the  tissue  removed 
showed  that  the  ejaculatory  ducts  had  not  been  disturbed.  In  fact  it 
is  an  easy  matter  to  attack  this  median  portion  even  when  not  enlarged 
and  not  injure  the  ducts,  which  are  quite  remote  in  this  region. 


118  Hugh  H.  Young. 

Perineal  Urinary  Fistulce. 

See  Chapter  on  Convalescence,  p.  93. 

Frequency  of  Urination  Due  to  Contracture  of  tlie  Bladder 

is  present  in  five  cases.  In  two  of  these  cases  (32,  70)  calculi  Avere 
present  before  operation.  In  both  of  these  cases  the  interval  be- 
tween urination  is  about  two  hours,  but  the  stream  is  large,  the 
patient  suffers  no  pain,  and  but  for  the  frequency  of  urination  the 
result  is  entirely  satisfactory.  In  three  cases  (10,  14,  105)  no  cal- 
culi were  present,  but  the  bladder  was  markedly  contracted,  the 
capacity  being  about  160  cc.  These  cases  have  been  free  from  resi- 
dual urine  since  the  operation,  and  urination  is  free,  painless,  and  the 
stream  is  large,  but  the  interval  between  urination  is  about  two  hours 
and  is  apparently  entirely  due  to  the  small  size  of  the  bladder. 

Cases  Now  Suggesting  the  Presence  of  Calculi. 

In  five  eases  the  reports  received  suggest  the  presence  of  calculi. 
In  all  of  these  cases  pain  was  a  prominent  S5^mptom  before  operation 
and  in  three  cases  calculi  were  present  and  removed  (85,  33,  45). 
In  these  cases  examination  with  a  searcher  after  operation  failed  to 
reveal  the  presence  of  calculus,  but  the  bladder  was  contracted  and 
considerable  cystitis  was  present.  In  two  cases  (46,  54)  the  symptoms 
strongly  suggested  vesical  calculi,  but  owing  to  hemorrhage  cysto- 
scopic  examination  was  unsatisfactory.  A  careful  search  failed  to 
reveal  any  calculi,  and  at  operation  none  were  removed,  but  no  notes 
have  been  made  as  to  whether  a  very  careful  search  was  made.  One 
of  these  patients  (54)  considers  himself  entirely  cured  although  he 
suffers  from  "  a  scalding  pain  when  the  bladder  is  nearly  empty." 
The  other  case,  however,  complains  of  frequent  and  painful  urination, 
and  other  symptoms  of  vesical  calculus  are  present. 

A  review  of  these  five  cases  in  which  pain  is  present  suggests  that 
stones  have  formed  since  the  operation  in  three  cases,  and  that  in  one 
case  at  least  calculi  were  present  before  operation  and  were  not  re- 
moved (46).  It  is  only  necessary  to  examine  a  few  autopsy  specimens 
to  see  how  easy  it  would  be  to  fail  to  detect  calculi  with  a  searcher 
before  operation  and  in  some  cases  to  find  them  at  operation  in  these 
cases.  The  frequent  presence  of  pouches,  diverticula,  and  pockets 
l)ohind  enlarged  lobes  is  one  of  the  strongest  arguments  for  the  neces- 


study  of  IJfd  Cases  of  Perineal  Prostatectomy.  119 

sity  of  cystoscopy  before  operation.  I  feel  sure  that  in  many  of  the 
cases  in  which  calculi  were  present,  had  I  not  been  aware  of  the  fact 
from  previous  cystoscopic  examinations,  they  would  not  have  been 
found.  Often  it  was  only  after  repeated  endeavors  and  careful  search- 
ing with  forceps  and  scoops  that  the  calculi  were  finally  removed.  It  is 
remarkable  how  seldom,  however,  calculi  encysted  in  diverticula  have 
been  found,  there  being  only  one  case  in  which  this  condition  was 
present.  In  this  case  a  suprapubic  prostatectomy  was  performed  after 
the  calculi  had  been  removed  from  the  diverticulum.  In  such  cases 
the  suprapubic  route  is  distinctly  preferable,  though  it  should  be  pos- 
sible to  remove  small  calculi  from  diverticula  with  large  orifices 
through  the  perineum,  if  the  location  of  the  diverticula  is  definitely 
determined  by  the  cystoscope  beforehand. 


Two  Cases  Report  a  Peculiar  MarTced  Nocturnal  Frequency  of 

Urination. 

One  of  these  cases  (8)  was  characterized  by  a  small  inflammatory 
prostate,  severe  cystitis,  and  vesical  irritability.  The  patient  con- 
siders himself  greatly  improved  by  the  operation,  but  urination  is 
particularly  frequent  at  night.  In  the  second  case  (35)  the  patient 
is  now  80  years  of  age.  The  prostate  was  very  large,  and  the  blad- 
der contracted  and  a  severe  cystitis  present.  Urination  is  free,  the 
patient  can  empty  bladder  and  retains  urine  for  three  hours  during 
the  day,  but  during  the  night  he  frequently  voids  from  10  to  20 
times.  In  some  cases  nocturnal  frequency  is  explainable  by  a  mark- 
edly increased  production  of  urine  during  the  night,  but  in  these  two 
cases  no  such  explanation  seems  applicable. 

An  interesting  case  is  (106),  in  which,  although  there  is  no  residual 
urine  present  and  the  bladder  capacity  is  360  cc.  the  patient  voids  at 
intervals  of  two  hours,  night  and  day,  and  not  more  than  180  cc. 
at  a  time.  Urination  is  free  and  there  is  no  explanation  for  this 
frequency  unless  it  be  cystitis. 

Becto-Urethral  Fistulce 
are  present  in  two  cases.     Both  are  minute  and  give  very  little  dis- 
comfort.    In  both  cases  urination  is  normal  at  normal  intervals,  and 
the  patients  suffer  no  inconvenience  (cases  26  and  42). 


130  Hugli  E.  Young. 

Incontinence  of  Urine. 
Although  incontinence   of  urine  "u-as  present  before  operation  in 
six  cases  it  has  persisted  since  operation  in  only  one  case,  the  history 
of  which  is  briefly  as  follows: 

(119). — ^Age  55,  admitted  November  4,  1905.  Gonorrhoea  36  years  ago, 
no  note  as  regards  sj-philis.  Two  j-ears  ago  he  began  to  have  severe  inter- 
mittent pains  in  his  legs.  About  the  same  time  he  began  to  have  a  decrease 
in  his  sexual  powers,  a  feeling  of  discomfort  in  the  region  of  the  bladder 
and  incontinence  of  urine.  He  was  catheterized  and  a  large  amount  of 
residuum  was  withdrawn,  since  then  he  has  occasionally  had  complete 
retention  of  urine.  The  incontinence  and  pains  have  persisted,  but  the 
catheter  is  necessary  three  times  daily.  On  admission  the  retention  of 
urine  was  complete  and  the  bladder  very  large.  The  prostate  was  only 
slightly  enlarged,  the  cystoscope  showing  a  small  median  bar.  Examin- 
ation showed  a  decrease  in  the  deep  reflexes,  but  the  only  sj'mptoms  of 
tabes  were  loss  of  sexual  power  and  the  history  of  lightning  pains.  (See 
complete  history.) 

At  operation  slightly  enlarged  lateral  lobes  and  a  small  middle  lobe 
were  removed.  The  convalescence  was  satisfactory,  the  fistula  closing 
on  the  14th  day  and  the  patient  leaving  the  hospital  on  the  18th  day. 
He  was  able  to  retain  urine  for  six  hours  at  night,  but  during  the  day 
there  was  incontinence  which  has  persisted  up  to  the  present  time.  Five 
months  after  the  operation  he  began  to  have  peculiar  painful  seizures 
in  the  abdomen,  a  girdle  sensation  with  an  extremelj^  sensitive  area  eight 
Inches  wide  around  the  body,  corresponding  to  the  lower  dorsal  and  sacral 
segments.  His  physician  writes  that  he  is  convinced  that  he  has  spinal 
disease.  The  patient  reports  (May,  1906),  that  he  voids  urine  naturally 
at  intervals  of  three  or  four  hours,  during  the  day  and  only  once  at 
night,  that  there  has  never  been  any  nocturnal  incontinence  and  that 
his  ability  to  retain  urine  during  the  day  is  improving. 

Three  patients,  all  very  old  men  (78,  80,  and  85  years  of  age)  re- 
port that  occasionally,  when  the  bladder  is  allowed  to  become  very 
full,  and  the  desire  to  urinate  is  imperative,  and  unless  a  urinal  is 
near,  a  few  drops  of  urine  may  escape.  In  two  of  these  cases 
(93,  128)  this  happens  but  seldom,  causes  no  inconvenience,  and  can- 
not be  considered  incontinence.  In  third  case  (16)  there  is  apparently 
a  slight  weakness  of  the  sphincter.  In  this  case  the  prostate  was  huge 
and  in  its  removal  through  the  perineum  it  was  necessary  to  excise  a 
good  deal  of  the  mucous  membrane  covering  the  median  portion  of  the 
prostate,  and  the  vesical  neck  was  left  greatly  dilated.  Perhaps  this 
has  something  to  do  with  the  sphincteric  weakness. 

In  reviewing  these  cases  it  seems  highly  probable  that  spinal  disease 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  121 

is  responsible  for  the  only  definite  case  of  incontinence  which  I  have 
had  as  a  result  of  perineal  prostatectomy  by  this  method.  These  sta- 
tistics absolutely  disprove  the  statements  of  Freyer  and  others  that 
incontinence  frequently  results  from  perineal  prostatectomy.  In  the 
technique  which  I  employ  both  external  and  internal  sphincters  are 
usually  left  intact,  and  incontinence  should  never  occur,  and  does  not 
as  my  cases  show.  In  cases  where  the  prostatic  lobes  are  removed 
through  a  median  perineal  incision  involving  the  external  sphincter 
of  the  urethra,  and  where  the  prostate  has  been  excised  after  hemi- 
section  of  the  posterior  surface,  as  employed  by  Albarran,  a  good 
portion  of  the  urethra  being  sacrificed,  it  is  easy  to  understand  how 
incontinence  may  occur. 

Pain. 

Although  pain  was  a  very  prominent  symptom  in  50%  of  the  cases 
(occurring  in  76  cases  before  operation,  in  61  cases  being  considerable, 
and  often  excruciating)  there  are  only  four  cases  in  which  the  pain 
has  been  considerable  since  operation.  One  of  these  cases  (51)  had  a 
recurrence  of  prostatic  obstruction  and  has  been  mentioned  above. 
Two  of  the  cases  (45,  33)  had  calculi  and  it  seems  probable  that  they 
are  again  present.  The  fourth  case  (46)  is  one  in  which  calculi 
were  suspected  but  could  not  be  found,  and  the  painful  symptoms 
have  persisted. 

In  three  cases  (85,  54,  4)  urination  is  entirely  satisfactory  with 
the  exception  of  a  slight  pain  which  comes  on  at  the  end  of  urination. 
In  one  of  these  cases  a  calculus  was  removed  at  operation;  in  the 
second  it  was  suspected  but  was  not  found,  and  in  the  third  several 
were  passed  after  operation.  In  the  remaining  cases  the  patients  are 
entirely  free  from  pain,  with  the  exception  of  a  few  instances  in  which 
a  burning  sensation  or  slight  pain  is  present  in  the  urethra  during 
urination.  All  of  these  patients,  but  one,  have  cystitis.  It  is  indeed 
remarkable  that  so  few  patients  complain  of  any  pain  although 
cystitis  in  more  or  less  severe  degree  is  present  in  the  great  majority 
of  cases.  Two  good  examples  of  the  complete  disappearance  of  very 
severe  pain  are  cases  96  and  102. 

The  Preservation  of  Sexual  Powers. 
In  an  earlier  part  of  this  paper  condition  of  patients  as  regards 
sexual  powers  were  given  in  tabulation.     As  stated  there  the  sexual 


122  Hugh  H.  Young. 

powers  in  those  under  50  years  of  age  were  normal  in  100%  of  the 
cases. 

Between  50  and  60  years  of  age  erections  were  normal  in  78%  of 
the  cases  noted,  and  present  but  impaired  in  11%,  and  coitus  was 
normal  in  74%  of  the  cases  noted,  and  present  but  impaired  in  21%. 

Between  the  ages  of  60  and  69  erections  were  normal  in  55%  of 
the  cases,  and  impaired  in  25%.  Coitus  was  normal  in  38%  and 
present  but  impaired  in  32%. 

Between  the  ages  of  70  and  79  erections  were  present  in  32%  of 
those  noted,  and  impaired  in  14%.     Coitus  was  normal  in  21%. 

I  have  made  careful  inquiries  to  obtain  if  possible  the  present  con- 
dition of  all  cases  upon  which  I  have  operated,  and  the  following 
tabulation  will  show  the  condition  of  the  patients  before  operation 
and  their  present  status. 

I.  Erections  present  and  coitus  normal  before  operation,  ^1  cases 

Status  prsesens : 

Erections  returned,  28  cases: 
Coitus  satisfactory,  17  cases. 
Coitus  impaired,  5  cases. 
No  coitus  attempted,  6  cases. 
Ages  of  these  patients : 

37  years  1  Cases. 

40    to    49      "  1      " 

50     "     59       "  14       " 

60     "     69       "  11       " 

70     "     79       "  1       " 

Erections  not  returned,  8  cases : 
Ages: 

58  years    2   Cases. 

60    to    69       "        5       " 

70       "        1       " 

Eecent  cases  operated  within  the  last  month,  4. 
Not  heard  from,  1  case. 

II.  Erections  present  hut  coitus  impaired  before  operation,  1  case. 
Status  prsesens : 

Erections  returned,  coitus  still  impaired,  1  case. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  133 

III.  Erections  present,  coitus  not  performed  before  operation,  16 

cases. 
Status  prgesens : 

Erections  returned,  12  cases. 
Erections  not  returned,  4  cases. 

Ages  of  the  12  patients  in  which  erections  have  returned. 

56  years    1   Cases. 

60    to    69       "        5 

70     "     79       "        6       " 

IV.  Erections  and  coitus  impaired  before  operation,  18  cases. 

Erections  returned,  coitus  now  satisfactory,  8  cases. 
Erections  returned,  coitus  still  impaired,  5  cases. 
Erections  not  returned,  5  cases. 

V.  Erections  impaired,  coitus  not  possible  or  not  attempted  before 
operation,  7  cases. 

Erections  returned,  4  cases. 
Erections  not  returned,  3  cases. 

YI.  Erections  absent  before  operation  and  coitus  impossible  for  a 
considerable  period,  Jj.2  cases. 

Of  these  erections  have  returned  in  5  cases. 
Coitus  satisfactory,  3  cases. 
Coitus  not  attempted,  2  cases. 
Erections  not  returned,  37  cases. 

VII.  No  note  as  to  erections  and  coitus  before  operation,  19  cases. 
In  these  cases  erections  have  returned  in  no  case. 

J.    THE  PATHOLOGY  OF  PROSTATE  HYPERTROPHY  AS  SHOWN  BY  A  STUDY 

OF   120    CASES. 

(By  John  T.  Geraghty,  in  collaboration.) 
The  opinions  of  various  authors  regarding  the  nature  of  prostatic 
hypertrophy  are  varied,  and  numerous  pathological  varieties  have  been 
enumerated. 

Albarran  and  Halle,  as  the  result  of  their  study  of  100  cases,  recog- 
nized three  varieties  of  benign  hypertrophy,  (1)  a  glandular  form, 
(2)  a  fibrous,  and  (3)  a  mixed  form.  The  fibrous  form  is  rather 
rare,  there  being  only  three  cases  in  the  series  examined,  while  Motz 
in  30  cases  found  only  one. 


124  Hugh  H.  Young. 

Yirchow  thonglit  that  the  hypertrophy  was  due  to  the  formation  of 
lobular  tumors  which  he  described  as  hyperplastic  myomata,  but  also 
admitted  the  existence  of  a  rare  form  of  hypertrophy  produced  solely 
by  the  development  of  the  glandular  tissue.  Motz  has  seen  a  case 
of  this  rare  form  described  by  Virchow  and  applies  to  it  the  term 
diffuse  polyadenoma.  W'e  have  not  encountered  a  like  form  of  hyper- 
trophy in  our  series. 

According  to  Eindfleisch  and  many  others,  two  forms  exist,  a  so- 
called  soft  form,  glandular  in  character,  and  a  hard  form,  the  fibro- 
muscular.  Eindfleisch  considered  that  the  usual  prostatic  hypertrophy 
was  a  fibro-muscular  increase  of  the  peritubular  stroma  with  at  the 
same  time  lengthening  and  marked  folding  of  the  tubules  themselves 
The  first  changes  take  place  in  the  subepithelial  tissue,  and  the  peri- 
tublar  stroma  of  the  individual  gland  segments.  If  now  in  the 
further  development  there  is  a  rapid  growth  of  the  stroma  elements 
the  glands  are  destroyed  and  the  fibro-myomatous  form  of  hypertrophy 
is  the  result.  If,  however,  there  is  a  rapid  increase  in  the  gland  ele- 
ments at  the  same  time  that  the  interstitial  tissues  hypertrophy,  the 
glands  are  preserved  and  the  so-called  soft  form  is  produced.  Eind- 
fleisch thought  that  the  primary  change  was  in  the  stroma.  Alexan- 
der, Gouley,  Caminiti,  and  others  think  there  exist  two  periods  in 
prostatic  hypertrophy;  during  the  first  the  glands  develop  excessively 
and  in  the  second  an  excessive  development  of  the  stroma  occurs. 
Jores  insists  that  prostatic  hypertrophy  is  not  of  the  nature  of  a 
neoplasm  while  Albarran  and  Mansell  Moulin  consider  it  an  adenoma. 

Motz  holds  that  the  hypertrophy  is  a  hyperplasia  of  all  the  elements 
of  the  prostate  as  a  result  of  repeated  congestions  (which  of  course 
would  make  sexual  affairs  a  strong  etiological  factor). 

Velpeau  was  struck  by  the  microscopic  appearance  of  the  spheroidal 
tumors  which  one  sees  in  the  hypertrophied  prostate.  He  at  first 
considered  these  spheroids  to  be  of  a  fibrous  nature,  but  later  ad- 
mitted that  glandular  elements  may  take  part  in  their  formation. 

Ciechanowski  insists  that  the  hypertrophy  is  the  direct  result  or 
it  might  be  termed  the  end  result  of  chronic  prostatitis.  As  a  result 
of  the  prostatitis  the  excretory  ducts  become  narrowed  or  occluded 
with  a  consequent  dilatation  of  tributary  acini.  With  the  gradual  in- 
crease in  the  fibrous  tissue  resulting  from  the  prostatitis  the  dilated 
acini  are  divided  by  constricting  fibrous  bands  and  thus  is  produced 


study  of  lJj-5  Cases  of  Perineal  Prostatectomy.  125 

new  culs-de-sac.  N"owliere,  lie  saj's,  does  lie  find  any  evidence  of 
glandular  proliferation. 

Motz  in  a  recent  splendid  contribution  has  called  attention  to  the 
fact  that  hypertrophy  practically  always  begins  in  the  glands  close 
to  the  urethra.  Thus  we  see  that  numerous  opinions  regarding  the 
nature  of  prostatic  hypertrophy  are  held  and  numerous  theories  have 
been  proposed  to  explain  the  pathological  processes  in  this  common 
senile  affection. 

Although  many  differences  exist  regarding  the  varieties  of  prostatic 
hypertrophy  nearly  all  authors  of  recent  years  are  agreed  that  the 
glandular  form  is  the  most  frequent. 

Taking  as  a  basis  of  classification  the  composition  of  the  hyper- 
trophy we  have  been  able  to  distinguish  three  t}^es  of  cases:  (1) 
Glandular,  (2)  fibro-muscular,  and  (3)  inflammatory. 

The  first  two  forms  alone  represent  true  hypertrophies.  The  in- 
flammatory form  is  not  a  true  hypertrophy  but  we  include  it  because 
it  represents  a  form  of  obstructing  prostate  about  which  we  will  say 
more  later. 

Although  here  and  there  one  encounters  a  picture  typical  of  the 
glandular  and  the  fibro-muscular  varieties,  various  transitions  exist 
and  a  clear-cut  boundary  line  cannot  always  be  easily  drawn  between 
them.  This  classification  which  we  have  employed  is  not  to  be  under- 
stood as  representing  distinct  anatomical  varieties,  but  rather  ij]ies 
of  cases  which  are  but  different  phrases  of  evolution  of  the  same 
pathological  process.  Hypertrophy  is  to  be  considered  a  hyperplasia 
of  all  the  elements  of  the  prostate  the  various  elements  undergoing 
augmentation  in  different  prostates  and  often  in  the  same  prostate  in 
varying  degree.  We  have  every  transition  from  prostates  in  which 
the  glandular  tissue  entirely  dominates  the  field  to  those  in  which 
there  is  very  little  glandular  element  present  and  the  tissue  is  almost 
entirely  stroma.  This  stroma  in  one  instance  may  be  largely  con- 
nective tissue,  in  another  the  muscular  element  may  be  considerable, 
while  again  we  find  areas  in  which  muscle  exists  in  almost  pure  form. 

Various  combinations  may  be  present  in  the  same  prostate  so  that 
it  is  not  always  possible  to  draw  a  sharp  line  of  demarcation. 

The  various  forms  which  we  have  distinguished  in  our  study  of  120 
cases  occurred  in  the  following  frequency: 

Glandular    100 

Fibro-muscular    14 

Inflammatory  or  fibrous  6 

Vol.  XIV.— 10. 


136 


Hugh  H.  Young. 


Gross  appearance  of  glandular  form. — When  enucleated  the  surface 
is  usually  lobulated  and  the  consistency  is  generally  soft  and  elastic. 
On  cutting  into  such  a  prostate  the  tissues  may  be  more  or  less  sponge- 
like due  to  dilated  glandular  acini  while  here  and  there  are  seen  the 
gaping  orifices  of  small  retention  cysts  which  have  been  cut  across. 
An  abundance  of  secretion  oozes  forth.     Usually  the  cut  surface  pre- 


Fig.  a. — This  represents  a  picture  commonly  seen  in  the  glandular  form 
of  hypertrophy.  The  acini  are  for  the  most  part  dilated  and  several  have 
undergone  cystic  dilatation.     Epithelial  proliferation  is  active. 


sents  the  picture  of  numerous  spheroidal  tumors,  differing  in  size, 
separated  from  each  other  by  encircling  and  interlacing  bands  of  tis- 
sue of  a  denser  character  and  of  varying  thickness.  These  spheroidal 
lobules  project  beyond  the  surface  and  are  sometimes  distinctly  en- 
capsulated and  can  be  quite  readily  enucleated.  At  times  the  ten- 
dency to  formation  of  these  lobules  is  only  indistinct  and  the  picture 
presented  resembles  somewhat  that  of  a  diffuse  glandular  hypertrophy. 
The  interspheroidal  tissue  is  as  a  rule  largely  composed  of  a  fibro- 
muscular  stroma  although  sometimes  it  contains  a  fair  number  of 
acini.  In  less  glandular  prostates  the  spheroids  are  less  numerous 
with  an  increased  amount  of  interlobular  stroma  which  contains 
sparsely  disseminated  acini  or  the  spheroidal  bodies  may  be  numerous 
but  comparatively  poor  in  gland  acini.     In  such  prostates  the  tissue  is 


study  of  11^5  Cases  of  •Perineal  Prostatectomy.  127 

denser  and  more  compact  although  here  and  there  may  be  spongy- 
looking  areas  due  to  dilated  culs-de-sac. 

On  microscopic  examination  the  gland  tissue  for  the  most  part 
occurs  in  lobules  and  when  these  are  not  present  the  acini  seem  to  have 
a  tendency  to  segregate  in  well-defined  areas.  The  acini  are  usually 
dilated,  often  elongated  or  ovoid,  and  with  ratlier  complex  lumina 


^■?:;^*<-*®;iaife&fci^-~Swi®»^ST!<:3i.-^ 


:..;i  ^1" 


^.:  '*;' 


_  Fig.  B.— The  epithelial  activity  in  one  of  the  acini  shown,  has  resulted 
m  the  formation  of  capillary  loops.  Note  the  very  high  character  of  the 
epithelium. 


due  to  infolding  and  often  papillomatous-like   proliferation   of  the 
lining  wall  (see  Fig.  A). 

The  epithelium  lining  the  acini  presents  a  variety  of  pictures.  One 
acinus  may  be  lined  by  a  double  layer  of  cells,  the  internal  being  a 
high  cylindrical  type  with  the  nucleus  near  the  basal  end  and  an  in- 


128 


Hugh  H.  Young. 


ternal  layer  of  rather  cuboidal-shaped  cells.  Again  there  may  be 
but  a  single  layer  of  high  cj^lindrical  cells.  In  the  cnls-de-sac  where 
proliferation  is  active  there  may  be  beneath  the  layer  of  cylindrical 
cells  numerous  layers  of  i-ather  polygonal-shaped  cells.     Very  often 


Fig.  C. — A  very  glandular  form  of  hypertrqpliy.     The  acini  are  dilated 
and  show  a  rather  unusual  amount  of  intraacinous  proliferation. 


in  the  same  acinus  at  one  point  a  single  layer  of  cylindrical  cells  may 
be  seen  and  at  other  points  there  may  be  accumulated  heaps  of  small 
epithelial  cells. 

Occasionally  capillary  loopings  of  epithelium  are  noted  as  seen  in 


study  of  14-5  Cases  of  Perineal  Prostatectomy. 


129 


Fig.  B.  The  internal  layer  of  cells  lining  the  acini  in  the  hyper- 
trophied  prostate  is  much  higher  than  the  epithelium  lining  a  normal 
acinus.  In  areas  where  the  glandular  proliferation  is  active  the  walls 
of  the  acini  are  serrated  and  well-marked  papillomatous  projection 


Fig.  D. — A  higher  magnification  of  portion  of  the  field  shown  in  C. 
The  papillary  projections  in  some  instances  have  slender  pedicles  of 
stroma,  while  at  other  times  they  consist  only  of  knuckles  of  epithelium. 


into  the  lumina  of  the  dilated  acini  may  he  present  (see  Pigs.  C  and 
D).  More  or  less  numerous  culs-de-sac  which  have  undergone  cystic 
degeneration  are  encountered.     Sometimes  there  may  be  but  a  few  in 


130 


Hugh  H.  Young. 


a  given  area  and  again  cystic  degeneration  of  nearl}'  all  the  acini  within 
one  or  more  lohules  may  be  present  (see  Fig.  E).  These  acini  are 
usually  lined  by  a  sin,gle  layer  of  rather  flattened  epithelium  and 
rarely  give  evidence  of  a  proliferative  activity.  About  the  periphery 
of  the  spheroidal  lobules  the  tissue  is  as  a  rule  condensed  and  contains 


^^^t' 


^^   -6/-  ;/  f  'i      '■\        m- 

^   /u4v  ..  U 


At  : 


"^„ 


^'t 


\  < , 
#^4: 
'-^v^ 


.^ 


Fig.  E. — In  the  center  is  seen  a  rather  extensive  degree  of  cystic  dila- 
tation of  numerous  acini. 


acini  in  varying  numbers  most  of  which  are  compressed  and  elongated 
(see  Figs.  E  and  F). 

Fibro-muscular. — The  fibro-muscular  forms  seldom  reach  the  large 
size  attained  by  the  glandular.  The  largest  in  our  series  weighs 
25-Gr.,  while  all  the  very  large  prostates  are  of  the  glandular  type. 
The  consistencv  is  much  firmer  than  the  glandular  although  it  never 


study  of  llf5  Cases  of  Perineal  Prostatectomy. 


131 


has  the  induration  whicli  one  encounters  in  the  carcinomatous  pros- 
tate. On  section  it  is  less  succulent  and  distinctly  more  homogeneous 
in  appearance  although  isolated  spheroids  are  noted  which  may  be 
mostly  if  not  entirely  composed  of  a  fibrous  or  fibro-muscular  tissue. 


•// 


4  «J  ; 


Jj- 


Fig.  F. — A  section  from  the  periphery  of  a  hypertrophied  lobule  showing 
the  condensation  of  the  tissue  and  the  flattened  and  elongated  acini. 


The  surface  is  as  a  rule  moderately  lobulated.  The  dilated  orifices  of 
gland  acini  are  sometimes  seen  and  occasionally  small  retention  cysts 
are  noted.  The  gross  picture  presented  is  usiially  quite  different  from 
that  which  is  seen  in  the  glandular  forms. 

On  microscopic  examination  the  acini  are  rather  regular  in  outline, 


132 


Hugh  H.  Young. 


separated  by  broad  bands  of  stroma  and  seldom  show  much  signs  of 
active  gland  proliferation  (see  Fig.  G).  They  are  sometimes  dilated 
but  seldom  display  a  degree  of  cystic  degeneration  which  one  finds  in 
more  adenomatous  h}"pertrophies.  The  stroma  varies  a  great  deal  from 
one  which  is  mostly  connective  tissue  to  t^'pes  where  the  muscular 


':'J^ 


Fig.  G. — Represents  a  fibro-muscular  form  of  hypertrophy.     The  stroma 
is  much  in  excess  of  the  glandular  elements  compared  with  C. 


element  predominates  and  the  stroma  is  of  course  much  in  excess  of 
the  gland  element.  Both  the  adenomatous  and  fibro-muscular  forms 
contain  spheroids  in  varying  number. 

Fibrous. — Under  the  fibrous  or  inflammatory  form  of  hypertrophy 
we  have  included  a  very  interesting  group  of  cases  with  marked  pros- 
tatic sj'mptoms  and  partial  or  complete  retention  of  urine.  The  pros- 


study  of  llfo  Cases  of  Perineal  Prostatectomy.  133 

tates  in  this  group  are  not  enlarged  or  at  most  very  slightly  so  (cases 
87,  89,  101,  133,  137,  143). 

On  gross  examination  they  contain  no  spheroids,  but  the  cut  sur- 
face is  rather  homogeneous  and  apparently  fibrous.  These  are  not 
true  hypertrophies,  but  represent  a  type  of  prostatitis.  The  prostatic 
obstruction  is  consecutive  to  inflammatory  processes  which  produce  a 
fibrous  h}^erplasia  about  the  vesical  orifice  or  result  in  the  formation 
of  an  infiammatory  median  bar.  The  microscopic  examination  of  the 
median  bar  in  these  cases  has  always  demonstrated  its  inflammatory 
nature  while  the  lateral  lobes  present  no  changes  other  than  those 
noted  in  chronic  prostatitis. 

Chronic  prostatitis  has  been  found  very  frequently  in  our  series  of 
cases,  but  of  course  a  large  percentage  of  the  patients  were  leading  a 
catheter  life  or  suffering  from  chronic  cystitis.  N'aturally  then  one 
would  expect  prostatitis  to  be  a  frequent  complication.  A  well- 
marked  prostatitis  was  present  in  58% — a  slight  prostatitis  in  31%, 
viz.,  a  few  limited  areas  of  mild  prostatitis — no  prostatitis  was  found 
in  11%. 

We  have  before  referred  to  the  views  of  Ciechanowski  regarding  the 
role  which  prostatitis  plays  in  the  production  of  prostatic  hyper- 
trophy. A  review  of  Ciechanowski's  cases  shows  that  he  was  dealing 
almost  entirely  with  small  prostates  found  at  post-mortem  while  ours 
are  only  cases  requiring  operation. 

If  Ciechanowski's  views  as  to  the  etiology  (obstruction  of  the  excre- 
tory ducts)  are  correct,  one  would  naturally  expect  to  find  the  acini 
lined  by  a  flattened  and  not  by  a  tall  cylindrical  epithelium  as  we  have 
found.  As  the  process  of  glandular  proliferation  proceeds,  some  acini 
and  sometimes  groups  of  acini  probably  become  separated  from  the 
excretory  ducts  and  as  a  consequence  these  culs-de-sac  undergo  cystic 
dilatation.  In  such  acini  the  lining  epithelium  most  frequently  con- 
sists of  but  a  single  layer  of  flattened  epithelium.  Such  a  character 
of  epithelium  one  would  expect  in  all  the  acini  if  Ciechanowski's  views 
as  regards  the  formation  of  new  acini  were  the  correct  ones. 

Again  it  is  inconceivable  that  hypertrophy  of  large  size  and  rich 
in  gland  tissue  could  be  produced  by  any  process  similar  to  the  one  he 
describes. 

Chronic  prostatitis  vsdth  the  production  of  a  large  amount  of  fibrous 
tissue  is  generally  accompanied  by  atrophy  of  the  gland  elements 
rather  than  an  increase  in  their  volume.     In  our  examinations  the 


134  Hugh  H.  Young. 

areas  of  prostatic  tissue  where  the  chronic  inflammatory  tissue  forma- 
tion was  most  marked  tlie  acini  were  diminished  in  number,  often 
compressed  and  atrophic,  and  again  nothing  but  vestiges  of  former 
acini  remaining.  Furthermore,  in  11%  of  the  prostates  examined 
no  evidence  of  an  inflammatory  process  were  found.  Again  in  the 
vast  majority  of  cases  where  prostatitis  was  present  the  prostatitis 
was  confined  to  definite  limited  areas,  the  greatest  portion  of  the 
hypertrophied  tissue  being  free  from  inflammatory  infiltration.  We 
have  seen  one  case  where  the  prostatitis  was  entirely  confined  to  the 
peripheral  non-hypertrophied  portion  of  the  prostate.  Indeed,  one 
seldom  sees  any  prostatitis  in  the  areas  where  the  most  active  gland 
proliferation  is  in  progress. 

Lastly  there  is  distinct  evidence  of  gland  proliferation  such  as  one 
sees  in  other  glandular  organs. 

Arteriosclerosis. — The  arteriosclerotic  theory  of  Guy  on  has  prac- 
tically no  adherents  to-day.  Casper  insists  on  the  rarity  of  arterio- 
sclerosis, only  finding  it  in  four  out  of  24  hypertrophied  prostates  ex- 
amined and  practically  all  recent  writers  are  of  one  accord  on  this 
subject. 

In  54  prostates  we  found  only  10  with  rather  extensive  arterial 
thickening.  The  arteriosclerosis  when  present  is  usually  irregular  in 
distribution  in  one  portion  and  end-arthritis  of  considerable  degree 
being  present,  and  in  other  portions  the  vessels  appearing  practically 
normal. 

Development  of  prostatic  hypertrophy. — The  different  steps  in  the 
formation  of  the  new  gland  acini  can  often  be  followed  in  the  several 
areas  of  a  section  from  a  portion  where  active  proliferation  is  present. 
The  initial  activity  is  in  the  epithelium,  the  epithelial  increase  result- 
ing in  a  protrusion  or  folding  of  the  epithelial  lining  towards  the 
lumen  of  the  acinus,  this  being  the  line  of  least  resistance.  We  have 
seen  numerous  such  pictures  where  the  stroma  had  not  yet  followed, 
knuckles  of  epithelium  projecting  into  the  lumen  without  a  supporting 
pedicle  of  stroma.  At  other  points  one  sees  delicate  fibrils  of  con- 
nective tissue  pursuing  the  epithelial  proliferation  and  at  a  later  stage 
fibres  of  smooth  muscle  entering  into  the  composition  of  the  pedicle 
of  the  new-formed  villus.  By  the  continued  growth  of  these  protru- 
sions from  the  periphery  the  acinus  becomes  subdivided  and  new 
acini  are  formed.  One  sometimes  sees  two,  three,  or  more  acini,  which 
are  the  direct  descendants  of  a  single  original  acinus.     If  the  glandu- 


study  of  145  Cases  of  'Perineal  Prostatectomy. 


135 


lar  activity  is  very  pronounced  the  interacinous  stroma  may  consist 
of  but  very  delicate  fibrils  of  connective  tissue^  but  where  the  prolifera- 
tion is  slower  the  stroma  is  more  abundant.  It  is  the  primary  activity 
of  the  epithelium  which  stimulates  the  connective  tissue  and  muscular 
elements  of  the  stroma  to  activity. 

Prostatic  hypertrophy  is  not  a  diffuse  hyperplasia  of  all  portions  of 
the  prostate  but  a  h3rperplasia  which  begins  in  separate  foci  and  results 
in  the  formation  of  more  or  less  numerous  spheroidal  tumors  (see 
Figs.  H  and  I).  That  this  hypertrophy  always  begins  in  the  central 
group  of  glands  can  be  readily  seen  by  an  examination  of  pathological 
specimens  of  early  hypertrophy. 


Fig.  H. 


Fig.  I. 


Fig.  H. — A  cross  section  of  a  prostate  which  represents  an  early  stage 
of  hypertrophy.  The  small  spheroidal  tumors  have  formed  in  the  central 
portion  and  are  compressing  the  tissue  Immediately  surrounding  them. 

Fig.  I. — A  cross  section  of  a  hypertrophy  somewhat  more  advanced  than 
that  seen  in  H.  In  the  lower  portion  are  visible  the  ejaculatory  ducts  and 
the  dilated  orifices  of  some  gland  acini. 


Albarran  in  his  classical  studies  on  the  disposition  of  the  glands  of 
the  normal  prostate  has  shown  that  they  can  be  definitely  divided  into 
a  peripheral  and  a  central  group  of  glands.  The  central  group  can 
again  be  divided  into  distinct  segregations  of  glands  and  neoplastic 
processes  occurring  in  one  or  more  of  these  various  groups  produce 
the  different  anatomical  varieties  of  prostatic  hypertrophy.  Should 
hypertrophy  occur  in  the  subcervical  group  of  glands  immediately 
beneath  the  vesical  neck  or  in  the  prespermatic  group^  we  have  formed 
as  a  result  a  median  lobe  or  bar. 

As  the  hypertrophy  in  the  central  portion  increases  the  peripheral 
tissue  is  condensed,  thus  forming  a  pseudo-capsule  (see  Fig.  J). 


136  Hugh  H.  Young. 

It  is  inside  this  pseudo-capsule  that  the  usual  enucleation  is  per- 
formed. In  the  compression  of  the  peripheral  portion  of  the  pros- 
tate the  ejaculatory  ducts  are  pressed  towards  the  posterior  surface 
so  it  is  easy  to  understand  why  in  some  cases  of  suprapubic  pros- 
tatectomy the  ejaculatory  ducts  are  not  destroyed.  The  subcervical 
and  prespermatic  portions  can  be  removed  without  disturbing  them. 

Xature  of  prostatic  hypertrophy. — That  prostatic  enlargement  is  a 
true  hypertrophy  is  very  improbable  since  it  begins  at  a  period  when 
the  functional  activity  of  the  gland  is  on  the  decrease  while  the  hyper- 
trophies occurring  in  all  other  glandular  organs  are  at  a  much  earlier 
period.  Furthermore,  the  hypertrophy  is  not  diffuse  but  occurs  in 
distinct    well-defined    areas.      In    great    prostatic    enlargements    an 


s.jf^ 


Fig.  J. — The  hypertrophy  here  is  advanced  still  further  than  that  seen 
in  H  and  I.  The  central  portion  is  entirely  replaced  by  the  hypertrophied 
tissue  while  the  peripheral  portion  assumes  the  role  of  a  thickened  capsule 
in  the  periphery.  The  ejaculatory  ducts  are  seen  towards  the  posterior 
surface. 

astonishing  number  of  these  "  spheroids  "  may  be  present.  Each  of 
these,  however,  does  not  represent  a  primarj^  tumor  formation.  The 
growth  in  an  area  undergoing  hyperplasia  is  not  always  equal  at 
every  point,  the  result  of  this  inequality  being  the  production  of 
rmmerous  spheroids,  the  direct  descendants  of  one  primary  focus  of 
activity.  The  size  of  the  h^'pertrophy  depends  upon  the  number  and 
volume  of  these  tumor  formations. 

These  spheroidal  tumors  vary  in  their  composition.  Most  frequently 
they  are  fibro-myo-adenomata,  but  aU  variations  from  an  almost 
pure  adenoma  to  pure  myoma  or  fibroma  are  encountered.  The  pure 
myomata  and  fibromata  are  uncommon.     In  only  one  prostate  have  we 


study  of  14-5  Cases  of  Perineal  Prostatectomy. 


is: 


found  myomatous  nodules  (see  Fig.  K),  while  in  nearly  every  instance 
where  the  spheroids  were  entirely  fibrous  in  character  the  condition 
seemed  to  be  the  result  of  a  chronic  prostatitis,  vestiges  of  former  acini 


^v^'^jje*. 


vr,f  ^/^,«r^-| 


L  VM  N  FoKrf  ' 


','/. 


»    / 


?,   \ 


Fig.  K. — A  myomatous  nodule.  The  myomatous  hyperplasia  is  forcing 
the  glandular  elements  towards  the  periphery  where  they  form  small 
accumulations  of  compressed  acini. 

occasionally  persisting.  The  tissue  forming  the  periphery  of  the 
spheroids  usually  contains  sparsely  scattered  acini  which  are  com- 
pressed and  elongated.     Occasionally  in  the   interspheroidal   stroma 


138  Hugh  H.  Young. 

areas  of  gland  accumulation  are  seen  which  represent  new  tumors  in 
the  process  of  formation,  the  increase  in  growth  not  being  sufficient 
to  produce  condensation  of  the  surrounding  tissue.  At  other  times  a 
partial  condensation  is  noted. 

Epithelioma  adenoid. — Albarran  and  Halle  in  their  examination  of 
100  hypertrophied  prostates  obtained  from  autopsies  at  Hospital 
Necker  found  14  carcinomata  in  prostates  clinically  diagnosed  as  benign 
hypertrophy.  In  a  large  number  of  these  cases  the  macroscopic  ap- 
pearance did  not  suggest  malignancy,  and  the  picture  was  that  of  the 
ordinary  benign  hypertrophy.  It  was  only  on  microscopic  examina- 
tion that  in  certain  lobules  adenomatous  changes  were  discovered 
which  to  them  suggested  early  or  beginning  malignancy.  They  have 
applied  the  term  "  epithelioma  adenoid  "  to  these  changes  and  have 
classed  as  cancer  all  prostates  containing  areas  in  which  such  changes 
were  present. 

Out  of  120  enucleated  prostates  which  clinically  were  diagnosed  as 
benign  and  in  which  on  gross  examination  of  the  tissue  no  suspicion 
of  malignancy  was  entertained  in  only  one  was  distinct  carcinoma 
found  on  microscopic  examination.  In  this  prostate  a  small  carci- 
nomatous nodule  about  2  mm.  in  diameter  was  noted  in  an  otherwise 
benign  prostate  (see  No.  9  in  paper  on  carcinoma). 

We  have  not  infrequently  found  areas  where  active  gland  prolifera- 
tion was  proceeding  in  which  the  epithelium  lining  the  acini  and  the 
intraacinous  papillary  projections  presented  a  rather  wild  profusion 
and  showed  some  slight  involution  changes.  These  changes  were 
never  sufficiently  marked  to  warrant  more  than  a  mere  conclusion  that 
the  glands  were  displaying  changes  seen  also  in  carcinomata  and  cer- 
tainly would  not  justify  a  positive  diagnosis  of  carcinoma. 

It  is  very  doubtful  whether  the  deviations  described  by  Albarran 
and  Halle  should  be  considered  malig-nant  changes  since  adenomata 
may  display  so  many  variations,  some  of  which  may  closely  simulate 
malignancy,  but  still  remain  in  the  field  of  benign  tumors. 

Cases  with  sterile  urine. — It  seemed  interesting  to  see  whether  in 
eases  in  which  the  urine  is  sterile  the  prostate  would  be  free  from 
inflammation. 

In  three  cases,  in  which  the  urine  was  sterile  and  absolutely  free 
from  pus,  the  prostatic  secretion  was  obtained  by  massage.     In  two 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  139 

cases,  the  microscope  slicsved  no  pus  cells,  and  in  the  other  onh'  a  very 
few  pol}Tiuclear  leucocj^tes  were  present.  Spermatozoa  were  present 
in  all  three,  along  with  lecithin  and  granule  cells.  ^licroscopic  ex- 
amination of  the  tissues  removed  by  prostatectomy  showed  no  pros- 
t-atitis  in  one  case  in  which  no  pus  cells  were  present  in  the  secretion. 
In  the  other  case  the  specimen  has  been  lost.  In  the  third  case  in 
which  a  few  pus  cells  were  present  in  the  secretion,  the  microscope 
shows  a  glandular  hypertrophy  with  considerable  interstitial  and 
glandular  prostatitis. 

In  seven  cases  in  which  the  prostatic  secretion  was  obtained,  where 
the  urine  contained  pus  and  bacteria,  pus  cells  were  present  in  con- 
siderable number  in  all  cases,  and  the  microscope  showed  considerable 
prostatitis  in  the  tissues  removed  at  operation. 

The  urine  was  sterile  in  18  eases,  five  of  these,  however,  contained 
free  pus  in  all  three  glasses  and  the  sections  show  prostatitis.  In 
one  case  shreds  were  present  in  the  first  glass  of  urine,  but  the  second 
and  third  glasses  were  clear.  The  specimen  at  operation  has  been 
lost. 

The  urine  was  clear,  contained  no  pus  or  bacteria  in  12  cases.  Eight 
of  these  had  never  had  gonorrhcea,  but  in  two  cases  calculi  were  present, 
and  in  both  of  these  considerable  prostatitis  was  found.  In  the  six 
cases  in  which  no  calculi  were  present,  three  showed  no  evidence  of 
prostatitis.  In  one  specimen  there  were  only  a  few  areas  of  inflam- 
matory infiltration  and  in  one  there  was  considerable  prostatitis,  both 
glandular  and  interstitial.     The  specimen  from  the  sixth  case  was  lost. 

Among  the  18  cases  in  which  the  urine  was  sterile  pain  was  present 
in  10  cases  and  all  showed  evidence  of  more  or  less  considerable  pros- 
tatitis on  microscopic  examination  of  the  specimens. 

In  eight  cases  no  pain  had  been  present.  In  four  of  these  the 
specimen  showed  no  inflammation,  and  in  two  cases  it  was  very  slight, 
there  being  only  a  few  leucocytes  seen.  In  two  cases,  however,  there 
was  considerable  prostatitis  present. 

K.    COXCLUSIOXS. 

Prostatic  hypertrophy  is  of  neoplastic  nature  and  in  the  vast  ma- 
jority of  cases  is  of  an  adenomatous  or  flbro-myoadenomatous  form. 
Pure  mvomata  and  fibromata  are  occasionallv  seen. 


140  Hugh  H.  Young. 

The  characteristic  lesion  of  h3^ertrophy  is  the  formation  of  sphe- 
roidal tumors  which  arise  in  the  central  group  of  glands. 

The  primar}^  activity  is  in  the  epithelium  of  the  acini. 

Chronic  prostatitis  may  produce  obstruction  similar  to  true  pros- 
tatic hj'pertrophy,  but  does  not  lead  to  a  true  hypertrophy  of  the  gland. 

That  perineal  prostatectomy  is  applicable  to  all  forms  of  prostatic 
hypertrophy,  even  the  greatest  intravesical  enlargements  being  easily 
removable  through  the  perineum  (one  of  my  cases  weighing  240 
gm.)  is  shown  by  the  cases  reported  here. 

The  ease  of  access  to  the  prostate,  the  excellent  view  obtained,  and 
the  abilit}'  to  use  other  instruments  than  the  finger,  make  it  the  only 
reasonable  method  of  attacking  a  non-enucleable  fibrous  prostate. 

The  fact  that  a  large  percentage  of  enlarged  prostates  are  carcino- 
matous, and  that  these  if  taken  early  can  be  completely  eradicated 
through  the  perineum  by  an  operation  described  in  another  portion 
of  this  volume  renders  it  the  onl}^  justifiable  route  in  man}^  cases 
which  may  be  shown  to  be  cancerous  by  frozen  sections  prepared  at 
the  operation  while  the  operator  awaits  their  decision. 

While  some  prostates  can  be  shelled  out  more  quickly  through  the 
suprapubic  region,  the  convalescence  is  longer,  more  disagreeable 
and  more  fatal  than  after  the  perineal,  and  it  is  the  operator's  duty 
to  consult  his  patient's  welfare  rather  than  his  personal  convenience. 

The  method  of  conservative  perineal  prostatectom}^  employed  in  the 
preceding  cases  affords  an  excellent  view  of  what  one  is  doing,  avoids 
injury  of  all  important  structures,  preserves  the  urethra,  ejaculatory 
ducts  and  vesical  sphincter  intact,  so  that  control  is  sometimes  estab- 
lished immediately  after  the  operation,  and  permanent  incontinence 
never  results  from  it. 

The  fact  that  there  was  a  mortality  of  only  4.3%  in  163  cases,  five 
of  whom  were  over  80,  one  87,  and  21  over  '75  years  of  age,  that  many 
of  these  patients  were  in  bad  condition  and  two  in  extremis,  that  the 
earliest  death  was  eight  da3'S  after  the  operation,  and  the  majority 
were  after  the  third  week,  that  the  cause  of  death  in  not  one  case  was 
immediately  due  to  the  operation,  and  that  during  the  past  14  months* 
there  has  not  been  one  death  in  50  cases  shows  that  it  is  a  method  of 
wonderful  benignity. 

The  absence  of  stricture  and  incontinence,  and  also  of  rectal  fistula 

*Nov.  16,  1906.  There  liave  now  been  over  50  consecutive  cases  without 
a  death,  and  all  have  been  entirely  successful. 


study  of  Ilj-B  Cases  of  'Perineal  Prostatectomy.  141 

(since  its  cause  and  remedy  were  discovered)  show  that  they  are 
bugaboos  held  out  against  a  procedure  by  those  who  have  never  tried  it. 

The  complete  restoration  of  normal  urination,  except  when  some 
cystititis  and  vesical  contracture  was  present,  and  the  lasting  results 
obtained  testify  to  the  completeness  of  the  removal,  except  in  the  four 
cases  given  above  in  which  the  operator  did  not  do  what  the  cystoscope 
showed  should  be  done,  and  are  not  to  be  placed  against  the  method. 

The  complete  return  of  sexual  powers  in  nearly  all  cases  where 
present  before  operation  and  the  wonderful  restoration  of  lost  puis- 
sance recorded  in  five  cases  show  the  value  of  the  conservation  of  the 
ejaculatory  duets,  a  point  which  the  infrequency  of  epididymitis 
(12%)  also  attests.  These  results  demonstrate  that  with  a  careful 
anatomical  technique,  avoiding  non-obstructive  and  valuable  struc- 
tures (the  external  and  internal  sphincters,  the  urethra  and  ejacula- 
tory ducts)  with  the  excellent  drainage  afforded  through  the  peri- 
neum, perineal  prostatectomy  is  a  benign  procedure,  applicable  to  all 
forms  of  prostatic  enlargement,  affording  a  much  quicker  and  more 
comfortable  convalescence  than  suprapubic  prostatectomy,  and  fol- 
lowed by  permanent  results  as  good  as  could  be  expected  or  desired. 

After  having  tried  both  the  suprapubic  and  Bottini  methods,  and 
having  employed  them  in  30  and  85  cases,  respectively,  I  feel  I  can 
say  with  all  sincerity  that  the  results  obtained  by  me  did  not  compare 
in  any  way — ^mortality,  convalescence,  ultimate  results,  and  restora- 
tion of  normal  functions — ^with  the  results  obtained  by  "  Conservative 
Perineal  Prostatectomy.^^ 

I  wish  to  thank  Dr.  Halsted  and  Dr.  Bloodgood  for  many  courtesies. 

Literature. 

Albarran  and  Halle.     Annales  des  Maladies  des  org.  gen.  urin. 

Feb.  and  Mar.,  1900. 
Voilleime  et  Le  Dentu.     Traite  des  maladies  des  voies  urinaries, 

Vol.  II. 
EiNDFLEiscH.     Traite  d'Instal.  pathoL,  p.  627. 
MoTZ.     Contrib.  a  I'etude  d'hyp.,  de  la  Prostate,  Th.,  Paris,  1896; 

Annales  des  Maladies  des  org.  gen.  urin.,  Oct.,  1905. 

SociN".     Krank.  der  Prostata. 

Yelpean.     Quoted  by  Motz  above. 

JoRES.     Handbuch  der  Urologie,  by  Von  Frisch. 

GouLET.     New  York  Med.  Eecord,  1890,  Xo.  1. 

CiECHANOWSKi.     Ann.  des  Maladies  des  org.  gen.  urin.,  1901. 
Vol.  XIV.— 11 


143  Bugli  H.  Young. 

APPENDIX. 

Detailed  Eepoet  of  Ixdiyidual  Cases  in  145  Operations  by  Con- 

SEKVATITE  PERINEAL  PROSTATECTOMY  FOR  BeNIGN  HYPERTROPHY.' 

Case  1. — Moderate  enlargement  of  median  and  lateral  lobes  of  the  pros- 
tate.    Catheterism.     Cured. 

No.  726.  S.  T.  A.,  age  66,  married,  admitted  October  11,  1902.  No  his- 
tory of  gonorrhoea  nor  previous  urinary  trouble.  Onset  began  six  years 
ago  with  slight  diflBculty  of  urination.  During  the  next  four  years  there 
was  a  gradual  increase  in  the  difficulty  and  frequency  and  occasionally  a 
slight  incontinence.  About  six  months  ago  a  physician  treated  him  by 
dilatation  of  the  posterior  urethra,  under  which  treatment  the  patient 
rapidly  grew  worse,  and  for  the  past  two  months  retention  has  been  com- 
plete and  the  catheter  necessary  from  four  to  six  times  a  day.  He  has 
suffered  a  great  deal  of  late  with  tenesmus  in  the  lower  abdomen,  espe- 
cially during  the  trip  which  he  has  just  made  from  Honolulu  to  Balti- 
more. Recently  he  has  been  able  to  void  very  small  amounts  of  urine, 
but  if  he  is  not  catheterized  every  four  or  five  hours  he  suffers  very  se- 
vere pain  in  the  bladder.  Catheterization  at  times  is  very  difficult  and 
considerable  hemorrhage  Is  produced.  He  is  now  weak  and  exhausted 
from  his  long  trip. 

Examination. — The  patient  is  a  thin,  weak,  very  sick  looking  man.  A 
harsh,  aortic,  regurgitant  murmur  is  present.  Examination  of  kidneys 
negative.  On  the  lower  portion  of  the  abdomen  are  several  severe  burns 
due  to  hot  water  compresses.  He  is  unable  to  void  urine,  A  small  coude 
catheter  passes  with  ease;  350  cc.  of  urine  evacuated.  The  cystoscope 
shows  two  moderately  enlarged  lateral  lobes  joined  by  a  median  bar  with- 
out intervening  sulci.  The  bladder  wall  is  considerably  inflamed,  markedly 
trabeculated  with  numerous  pouches  and  some  diverticula.  The  ureters 
cannot  be  seen. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  smooth, 
round,  elastic,  fairly  soft  and  not  nodular.  Urine  is  acid.  Specific  grav- 
ity 1018.  Albumin,  fairly  heavy  cloud.  Pus  and  bacilli  in  great  numbers. 
Preliminary  treatment. — For  two  weeks  the  patient  was  catheterized 
about  every  three  or  four  hours  and  the  bladder  irrigated.  Water  and 
urotropin  in  abundance  were  administered  by  mouth.  Under  this  treat- 
ment the  irritability  of  the  bladder  disappeared  and  the  patient  became 

^  It  has  seemed  necessary  to  give  all  the  details  of  the  cases,  although 
consuming  great  space.  The  numbers  given  are  those  of  my  office  index, 
unless  "  S.  No."  is  used,  when  the  surgical  No.  of  the  Johns  Hopkins  Hos- 
pital Is  supplied.  In  the  later  reports  from  patients  by  letter,  quotation 
marks  are  not  used  because  their  replies  have  been  abbreviated  so  as  to 
save  space. 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  143 

much  stronger.  The  total  quantity  of  urea  varied  from  6  to  11  grams 
daily,  and  although  this  amount  was  very  small,  the  patient  seemed 
strong  enough  to  attempt  the  radical  operation. 

Operation,  October  24. — Ether.  An  inverted  Y-shaped  incision  was  made 
in  the  perineum.  The  central  tendon  and  recto-urethralis  muscles  were 
divided,  and  the  posterior  surface  of  the  prostate  divided  by  blunt  dis- 
section.    The  urethra  was  then  opened  upon  a  sound  in  the  membranous 


Fig.  39a. 

urethra,  and  after  dilatation  of  the  prostatic  urethra  the  single-bladed 
tractor,  Fig.  39a  (which  was  the  first  instrument  which  I  had  made  for 
this  purpose)  was  passed  into  the  bladder  with  ease,  and  the  beak  turned 
downward  over  the  median  portion  of  the  prostate.  Traction  was  then 
made,  and  it  was  found  possible  to  draw  the  prostate  so  far  downward  that 
it  was  almost  on  a  level  with  the  skin.  A  transverse  incision  was  then 
made   in   the   prostatic   capsule   near   the   apex.     A   blunt   dissector   was 


Fig.  40. — Lateral  lobes,  median  bar,  and  floor  of  urethra  removed  in  one 
piece. 

inserted  and  the  posterior  capsule  rapidly  freed  from  the  prostate.  The 
lateral  surfaces  were  likewise  freed.  An  effort  was  then  made  to  strip 
the  lobes  from  the  urethra,  but  with  only  partial  success,  and  when  the 
prostate  had  been  completely  enucleated  it  was  found  that  the  entire  floor 
and  a  portion  of  the  lateral  walls  of  the  urethra  (and  the  ejaculatory 
ducts)  had  been  removed  in  one  piece.  The  specimen  removed  consisted 
of  the  two  lateral  lobes  joined  by  the  median  bar,  as  shown  in  Fig.  40. 


144  Hugh  H.  Young. 

A  small  retention  catheter  was  passed  through  the  perineal  wound  into 
the  bladder.  The  lateral  cavities  were  not  packed  with  gauze,  but  the 
packing  was  placed  outside  of  the  capsule  so  as  to  force  it  up  against  the 
urethra  and  form  a  new  floor.  The  levator  muscles  were  brought  together 
on  each  side  by  silk  sutures  and  the  skin  wound  partially  closed  with  in- 
terrupted sutures.     The  patient  was  infused  on  the  table. 

Convalescence. — Immediately  after  the  operation  the  large  single  drain- 
age tube  became  plugged  with  blood  clots,  and  the  bladder  became  dis- 
tended with  urine,  necessitating  the  removal  of  the  gauze  and  tubes  be- 
fore the  clot  could  be  removed  and  the  urine  evacuated.  Considerable 
difliculty  was  experienced  in  Introducing  another  tube,  there  was  consid- 
erable hemorrhage  and  the  patient  was  quite  shocked.  The  wound  was 
repacked  with  gauze  and  after  that  the  patient  reacted  well.  Perineal 
drainage  was  kept  up  for  about  a  week  when  the  perineal  tubes  and  gauze 
were  removed.  Subsequently  a  retention  catheter  was  placed  in  the  ure- 
thra to  facilitate  closure  of  the  fistula. 

On  December  8  the  following  note  was  made:  The  patient  voids  urine 
without  difficulty  at  intervals  of  about  three  hours.  There  is  no  inconti- 
nence and  the  stream  is  large.  On  November  3  examination  showed  the 
bladder  capacity  to  be  210  cc.  The  bladder  has  been  dilated  through  a 
catheter,  and  it  now  holds  460  cc.  and  the  patient  can  void  as  much  as  300 
cc.  at  a  time.  He  has  had  slight  epididymitis.  The  patient  was  discharged 
December  8,  1902,  on  the  45th  day.  He  was  able  to  retain  urine  for  three 
hours  and  voided  naturally,  but  a  slight  fistula  was  present,  and  this  fin- 
ally closed  four  months  after  the  operation. 

January  1,  1903. — »I  void  urine  once  at  night  and  have  gained  eleven 
pounds  in  weight. 

May  28,  1903. — I  void  urine  naturally  four  times  during  the  day  and 
once  at  night.  There  is  no  incontinence.  I  have  erections,  but  have  not 
attempted   intercourse. 

February,  1901). — I  can  retain  urine  from  six  to  eight  hours.  Urination 
is  satisfactory.  I  have  no  pain;  erections  occur  occasionally,  but  I  have 
not  attempted  intercourse.     My  general  health  is  excellent. 

Islote. — The  patient  took  a  trip  to  South  Africa  and  lost  his  life  in  an 
accident  at  Victoria  Falls,  September  10,  1904. 

Pathological  report. — Specimen,  G.  U.,  63.  The  entire  prostate  has 
been  removed  in  one  piece  and  weighs  about  50  grams.  The  union  be- 
tween the  median  bar,  which  measures  about  2x3  cm.  in  size,  and  the 
lateral  lobes  has  not  been  disturbed;  and  the  mucous  membrane  covering 
the  front  of  the  median  bar  and  a  portion  of  the  internal  surfaces  of  the 
lateral  lobes  has  been  removed  along  with  the  lobes.  The  external  sur- 
face shows  numerous  small  lobules  covered  by  a  smooth  capsule,  and  the 
section  shows  some  enlarged  spheroids  in  an  enlarged  stroma.  The  con- 
sistence is  everywhere  elastic. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one.  The 
acini  are  dilated  and  show  considerable  papillomatous  intra-acinous  growth. 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  145 

The  epithelium  lining  the  acini  in  most  areas  shows  a  rather  profuse  pro- 
liferation. The  glandular  tissue  is  arranged  for  the  most  part  in  lobules, 
the  periphery  of  the  lobule  is  composed  of  compressed  stroma  containing 
elongated  acini.  In  the  middle  lobe  there  is  present  a  marked  prostatitis 
with  the  formation  of  a  great  deal  of  scar  tissue  in  the  stroma  which  in 
places  has  almost  completely  obliterated  the  acini.  The  arteries  in  these 
rather  fibrous  areas  show  considerable  thickening,  while  in  the  glandular 
areas  they  seem  about  normal.  There  is  a  moderate  amount  of  muscle 
present  in  the  stroma  except  in  the  areas  where  there  has  been  a  forma- 
tion of  quite  marked  inflammatory  tissue. 

Case  2. — Considerable  enlargement  of  median  and  lateral  lobes.  No 
complication.    Cure.    Followed  42  months. 

No.  368.  J.  W.  L.,  age  59,  married,  admitted  December  6,  1902.  Old 
Dominion  Hospital,  Richmond,  Va. 

Complaint. — "  Frequency  and  difiiculty  of  urination." 

No  history  of  gonorrhoea. 

In  1893  patient  had  nephritic  colic,  and  a  second  attack  in  1898,  no 
other  colic  since  then  but  has  frequently  passed  sand. 

Present  illness  began  in  1895  with  frequency  of  urination,  this  gradu- 
ally increased,  and  in  1898  complete  retention  of  urine  requiring  cathe- 
terization came  on.  Since  then  has  had  frequent  and  diflicult  urination 
and  occasionally  retention  requiring  catheterization. 

8.  P. — Urination  every  hour  with  great  difficulty.  No  history  of  hema- 
turia or  pain.    Has  lost  about  20  pounds  in  weight. 

Sexual  powers. — No  note  made. 

Examination. — The  patient  looks  pale,  but  his  muscular  strength  seema 
good.  The  heart,  lungs  and  abdomen  negative.  There  is  a  small  inguinal 
hernia  present. 

Rectal. — iProstate  is  considerably  enlarged,  about  the  size  of  a  small  or- 
ange. It  is  rounded,  smooth,  symmetrical,  elastic,  there  are  no  nodules 
or  areas  of  induration.     The  seminal  vesicles  are  not  palpable. 

Cystoscopy. — A  silver  catheter  passes  with  ease  and  finds  165  cc.  residual 
urine,  and  a  bladder  capacity  of  250  cc.  Cystoscopy  is  impossible  on  ac- 
count of  hemorrhage. 

Urinalyis. — Acid,  albumin  in  small  amount,  no  sugar,  urea  G-25  in  24 
hours.    Microscopically,  pus  cells  and  bacilli. 

Operation,  December  6,  1902. — Chloroform.  Perineal  prostatectomy.  In 
this  case  I  decided  to  operate  by  a  different  technique  so  as  to  preserve,  if 
possible,  more  of  the  prostatic  urethra  than  I  had  in  Case  1.  The  inverted 
Y-incision  was  used,  the  bulb  and  central  tendon  exposed,  and  central 
tendon  and  muscle  beneath  it  were  divided.  The  levators  were  separated 
by  the  fingers,  thus  exposing  the  membranous  urethra  which  was  incised 
upon  a  grooved  director  just  in  front  of  the  apex  of  the  prostate.  A  large 
sound  was  passed  into  the  bladder  through  the  opening  and  the  single 
bladed  tractor  easily  inserted  into  the  bladder  and  turned  downward  over 


146  Hugli  H.  Young. 

the  median  portion  of  ttie  prostate.  Outward  traction  was  ttien  made, 
drawing  the  tractor  well  up  into  the  wound.  A  V-shaped  incision  was  made 
through  the  prostatic  capsule,  the  point  being  forward  near  the  apex  of 
the  prostate.  With  a  blunt  dissector  the  capsule  was  then  rapidly  stripped 
back  from  the  posterior  surface  of  the  prostate  until  the  entire  posterior 
and  lateral  surfaces  had  been  separated  from  the  capsule  which  was  thus 
turned  back  as  a  cuff.  In  order  to  preserve  the  urethra  the  prostate  was 
then  bisected,  beginning  in  the  median  line  at  the  apex  and  extend- 
ing backward  for  1%  cm.  In  order  to  separate  the  urethra  from  the 
lateral  lobes  it  was  found  necessary  to  make  a  longitudinal  incision  on  each 
side  with  the  scalpel  parallel  to  the  urethra.  A  blunt  dissector  was  then 
inserted  and  the  urethra  rapidly  stripped  away  from  the  inner  surface 
of  each  lateral  lobe  (this  was  practically  the  method  of  Proust  which 
I  had  not  heard  of  at  that  time) .  The  lateral  lobes  were  then  enucleated 
and  removed  each  in  one  piece,  the  tractor  being  turned  so  as  to  engage 
each  lobe,  while  it  was  being  enucleated.  A  median  lobe  2  cm.  in  diameter 
was  then  drawn  down  by  the  tractor  into  the  urethra  and  enucleated  to- 
gether with  a  narrow  strip  of  mucous  membrane  which  covered  its  anterior 
surface,  the  verumontanum  and  the  terminal  portions  of  the  ejaculatory 
ducts.  During  this  operation  considerable  difficulty  was  experienced  in 
employing  the  tractor  which  continually  slipped  out  and  had  to  be  intro- 
duced with  considerable  difficulty.  (This  led  to  the  addition  of  a  shoul- 
der to  the  end  of  the  blade  to  prevent  its  slipping  out) .  A  large  reten- 
tion catheter  was  passed  into  the  bladder.  One  small  piece  of  gauze  was 
packed  into  the  prostatic  cavity  and  two  pieces  were  placed  back  of  the 
prostatic  capsule,  the  object  being  to  cause  the  collapse  of  the  cavity 
after  removal  of  the  piece  of  gauze  from  the  interior  of  the  capsule.  The 
separated  levator  muscles  were  joined  with  sutures  of  catgut  and  the 
wound  was  partially  closed  with  catgut  externally.  The  patient  stood  the 
operation  well.     Saline  infusion. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
100.50.  "When  last  seen  by  the  operator,  30  hours  after  the  operation,  his 
condition  was  excellent.  He  was  discharged  on  the  14th  day  in  excellent 
condition. 

May  24,  1904. — Letter.  The  wound  has  remained  closed.  I  void  urine 
with  perfect  satisfaction  at  intervals  of  from  two  to  four  hours  during 
the  day  and  four  to  six  hours  at  night.  I  suffer  no  pain  and  my  general 
health  is  excellent. 

May  20,  1906. — ^Letter  from  physician.  Micturition  is  normal.  He  voids 
about  every  three  hours  during  the  day  and  one  to  three  times  at  night. 
There  is  no  evidence  of  stricture  and  very  rarely  a  little  dribbling.  His 
condition  is  fine. 

Pathological  report. — Specimen,  G.  U.  60.  The  entire  prostate  has  been 
removed  in  three  pieces  and  weighs  70  grams.  The  median  lobe  measures 
3  X  2  X  iy2  cm.,  the  lateral  lobe,  each  5x4x3  cm.  The  summit  of  the 
median  lobe  is  covered  by  mucous  membrane  about  l^o  cm.  in  diameter. 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  147 

The  appearance  of  the  lobes  exteriorly  and  on  cross  section  is  that  of 
numerous  spheroids;  they  are  elastic  and  there  are  no  areas  of  induration. 
Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one,  areas  rich  in  acini  and  forming  spheroids  alternating  with  areas  con- 
taining rather  a  large  amount  of  stroma.  Often  the  tissue  outside  of  these 
spheroids  contains  numerous  culs-de-sac,  showing  signs  of  activity.  The 
stroma  contains  a  large  amount  of  muscle,  at  times  being  considerably  in 
excess  of  the  connective  tissue.  There  is  present  in  areas  a  well  marked 
chronic  prostatitis  and  the  blood  vessels  exhibit  a  moderate  degree  of  ar- 
teriosclerosis. 

Case  3. — Moderate  hypertrophy  of  prostate.  Catheter  life  I4  years. 
Tabes  dorsalis  of  16  years'  duration.  Restoration  of  normal  urination. 
Followed  5  months. 

No.  297.    T.  C.  L.,  age  60,  married,  admitted  November  17,  1902. 

Complaint. — "  Enlarged  prostate.     Catheterism." 

Gonorrhoea  many  years  ago,  and  was  perfectly  cured. 

In  1863  had  a  sore  on  the  penis  which  he  thinks  was  syphilitic.  His 
physician  told  him  that  he  had  blood  poison  and  gave  him  internal  treat- 
ment which  he  took  for  a  month.  Sixteen  years  ago  he  began  to  have 
sharp  severe  pains  which  came  on  suddenly,  and  were  localized  in  the 
right  thigh  and  later  in  the  right  leg.  No  trouble  with  bladder,  rectum 
or  locomotion  at  that  time. 

Present  illness  began  14  years  ago  with  difficulty  and  frequency  of  uri- 
nation. About  the  same  time  he  began  to  have  incontinence  of  urine  at 
night.  After  three  months  his  condition  was  not  improved,  and  his  phy- 
sician passed  a  catheter  withdrawing  about  a  quart  of  residual  urine. 
The  diagnosis  of  enlarged  prostate  was  made.  Following  this  examination 
the  patient  had  a  chill,  fever  and  pain  in  the  region  of  the  left  kidney.  He 
was  unable  to  pass  urine  except  in  very  small  amounts  and  with  great 
difficulty  and  began  a  catheter  life  which  has  continued  up  to  the  present 
time.  He  has  continued  to  suffer  greatly  from  "  sciatica."  Two  years  ago 
he  noticed  for  the  first  time  an  instability  of  gait,  particularly  at  night. 
Recently  his  eyesight  has  become  impaired. 

8.  P. — The  patient  is  unable  to  void  and  catheterizes  himself  five  times 
a  day.  His  general  health  is  good,  has  not  lost  weight,  but  he  still  suffers 
from  an  occasional  attack  of  "  sciatica,"  and  instability  of  gait. 

Sexual  powers. — Erections  have  been  absent  for  many  years.  He  finds 
the  catheter  life  a  terrible  burden  and  begs  to  be  relieved  from  it. 

Examination. — The  patient  is  a  sparely  built,  but  healthy-looking  man 
with  lips  of  good  color.     The  chest  and  abdomen  are  negative. 

Examination  of  nervous  system  by  Dr.  Thomas. — Vision  good,  optic 
nerves  are  normal.  The  pupils  are  contracted,  there  is  no  reaction  to  light 
and  very  slight  reaction  to  accommodation,  the  other  cranial  nerves  are 
normal.  The  walk  is  slightly  ataxic.  There  is  a  marked  swaying  with 
his  feet  together  and  eyes  closed.     The  knee  and  ankle  jerks  are  absent. 


148  Hugh  H.  Young. 

There  is  a  marked  lack  of  muscle  tone  and  a  retardation  of  the  perception 
of  pain  throughout  the  legs.  No  other  very  pronounced  sensory  disturb- 
ance. 

Diagnosis. — Tabes  dorsalis  with  unusual  involvement  of  the  bladder. 

Rectal. — The  prostate  is  moderately  but  very  definitely  hypertrophied, 
forming  a  bulging  rounded  mass  about  the  size  of  a  small  orange,  smooth, 
elastic,  but  harder  than  usual.  The  lateral  lobes  are  about  equally  en- 
larged, the  median  furrow  and  notch  are  obliterated.  The  seminal  vesicles 
are  not  indurated,  and  there  are  no  palpable  glands.  The  sphincter  ani 
is  peculiarly  lax  and  atonic  and  the  rectal  mucosa  is  very  redundant. 

Cystoscopic. — A  coude  catheter  enters  easily,  retention  of  urine  is  com- 
plete, bladder  capacity  600  cc,  the  tonicity  poor.  The  cystoscope  shows  a 
definite  rounded  intravesical  hypertrophy  of  both  lateral  lobes  and  fairly 
deep  sulcus  between  them  in  front,  and  a  small  median  lobe  with  a  shal- 
low sulcus  on  each  side.  The  ureters  could  be  easily  seen  and  they  are 
situated  in  prominent  ridges.  The  bladder  wall  is  only  slightly  trabecu- 
lated  and  there  are  no  large  ridges  with  deep  pouches  intervening. 

Urinalysis. — tCloudy,  alkaline,  sp.  gr.  1022,  no  albumin,  no  sugar.  Total 
quantity  of  urine  760  cc.  Total  urea  G-14.5.  Microscopically,  pus  cells 
and  bacteria. 

Note. — 'It  seemed  very  evident  from  the  history  and  age  of  the  patient 
that  the  urinary  trouble,  which  began  14  years  before,  was  due  to  tabes. 
There  was  no  question,  however,  of  the  fact  that  the  prostate  was  then 
distinctly  hypertrophied,  and  that  possibly  prostatectomy  might  restore 
normal  urination,  though  it  might  also  lead  to  incontinence.  The  patient 
was  going  to  Boston,  and  I  asked  him  to  see  Dr.  A.  T.  Cabot,  who  advised 
prostatectomy.  Dr.  H.  M.  Thomas,  who,  after  careful  examination,  had 
confirmed  our  diagnosis  of  tabes  dorsalis,  thought  that  prostatectomy  might 
have  the  desired  effect.  The  patient  was  so  anxious  to  get  rid  of  the 
catheter  that  he  gladly  accepted  the  chance  of  continual  incontinence. 

Operation,  Dec.  9,  1902. — Ether.  Perineal  prostatectomy.  This  was  the 
third  case  operated  upon,  and  the  following  technique  was  used.  A  median 
line  perineal  incision,  insertion  of  a  single-bladed  tractor  through  ure- 
throtomy of  membranous  urethra.  Inverted  V-incision  through  capsule  of 
prostate  which  was  stripped  back,  thus  exposing  the  posterior  surface  of 
the  prostate.  Hemisection  of  the  urethra  was  then  performed  in  the  median 
line,  and  the  urethra  separated  from  each  of  the  lateral  lobes  beginning 
with  an  incision  and  completed  by  blunt  dissection.  The  lateral  lobes  were 
then  enucleated  each  in  one  piece.  The  right  lobe  measured  3x3x4  cm. 
The  left  lobe  3x4x4  cm.  Examination  of  the  median  portion  showed 
very  little  enlargement,  not  sufficient  to  warrant  removal.  Large  drain- 
age tube  was  placed  in  the  bladder  through  the  perineal  wound,  the  cap- 
sule was  drawn  forward  and  sutured  so  as  to  surround  the  tube.  Two 
gauze  packs  were  placed  back  of  the  prostatic  capsule  with  the  object  of 
obliterating  it.  The  levator  muscles  were  drawn  together  with  sutures 
and  the  skin  wound  partially  closed.  Infusion  at  end  of  operation.  Pulse 
94,  condition  excellent. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  149 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to  101° 
for  three  days  after  the  operation,  after  which  it  was  practically  normal. 
He  suffered  greatly  from  severe  attacks  of  pain  in  both  legs,  which  came 
on  suddenly  and  were  very  severe,  but  lasted  only  a  few  minutes.  Intra- 
vesical irrigations  of  boric  acid  were  given  twice  daily  until  the  tube  was 
removed  on  the  ninth  day.  The  gauze  was  removed  on  the  next  day  and 
the  patient  was  gotten  up  in  a  wheel-chair.  Two  weeks  after  the  opera- 
tion urine  began  to  flow  through  the  meatus.  The  retained  catheter  was 
then  placed  in  the  urethra,  where  it  remained  for  eight  days.  After  its  re- 
moval there  was  no  leakage  through  the  perineum,  which  remained  healed. 
He  was  discharged  from  the  hospital  on  the  42d  day.  At  that  time  he  was 
able  to  retain  urine  for  three  hours  during  the  day  and  eight  hours  at 
night.  There  was  no  dribbling  at  all  during  the  night,  and  during  the 
day  there  was  only  occasionally  when  walking  about  an  involuntary  es- 
cape of  a  few  drops  of  urine.  Micturition  is  slow,  but  without  difficulty, 
and  when  the  bladder  was  quite  full  the  stream  was  good.  A  catheter  was 
passed  with  ease  and  found  no  residual  urine.  The  bladder  had  become 
slightly  contracted  and  would  hold  only  340  cc.  The  vesical  tonicity  was 
better  than  before  operation,  but  was  still  only  moderately  good.  The 
patient  was  instructed  to  use  urotropin  two  or  three  times  a  day,  and  to 
irrigate  the  bladder  with  boric  acid. 

February  6,  1903. — "  "While  irrigating  the  bladder  by  hydraulic  pressure 
the  perineal  wound  broke  open  again.  There  is  now  slight  leakage,  other- 
wise the  condition  is  good." 

March  12,  1903. — "  I  am  able  to  urinate  all  right,  but  the  perineal  fis- 
tula is  still  open  and  a  few  drops  of  urine  escape  through  it  during  urina- 
tion."    He  was  advised  to  cauterize  the  wound. 

May  21,  1903. — Letter  from  wife.  On  March  16  the  patient  had  a  sudden 
severe  collapse  which  was  thought  to  be  uremic.  He  seemed  to  rally  from 
this,  but  the  old  enemy  "  neuralgia  "  kept  coming  with  the  least  exposure 
to  cold  and  these  attacks  kept  him  indoors.  The  strain  weakened  him, 
and  finally  the  stomach  lost  its  tone,  his  appetite  failed,  the  bowels  became 
affected,  dysentery  set  in,  and  at  the  end  of  two  weeks  death  ensued.  May 
20,  1903. 

Pathological  report. — Specimen,  G.  U.  61.  The  prostate  has  been  removed 
in  two  pieces  and  weighs  50  grams.  The  right  lobe  measures  5  x  4  x  3^^ 
cm.,  the  left  4.5  x  4  x  3  cm.  No  mucous  membrane  has  been  removed.  Ex- 
ternally and  on  section  numerous  small  lobules  and  spheroids  are  seen. 
There  are  no  areas  of  induration  nor  suggestion  of  malignancy. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one.  The  acini  are  grouped  in  small  spheroidal  areas,  and  the  interlacing 
stroma  contains  but  very  few  acini.  The  stroma  contains  a  fair  amount 
of  muscle,  but  the  connective  tissue  is  somewhat  in  excess.  The  blood  ves- 
sels show  a  marked  degree  of  arteriosclerosis. 


150  Hugh  E.  Young. 

Case  4. — Moderate  hypertrophy  of  median  and  lateral  loies.  Vesical 
calculus.    Cure.    Follotved  tico  years. 

370.     J.  P.  D.,  age  57,  married,  admitted  Dec.  17,  1902. 

Complaint. — ■"  Frequent  and  painful  urination." 

The  patient  never  had  gonorrhoea. 

Present  illness  began  about  17  years  ago  with  slight  diflBculty  and  in- 
creased frequency  of  urination.  About  five  years  ago  he  had  complete  re- 
tention of  urine  and  had  to  be  catheterized  for  two  days.  Since  then  he 
has  had  complete  retention  at  gradually  lessening  intervals,  but  alwaj's 
after  two  days  he  would  be  able  to  void  again.  He  has  had  a  pain  occa- 
sionally during  and  at  the  end  of  urination,  but  there  has  been  no  pain 
in  the  rectum. 

jS.  p. — 'The  patient  now  voids  three  or  four  times  during  the  night  in  a 
small,  slow  stream.  He  dees  not  use  the  catheter  unless  unable  to  uri- 
nate.    Sexual  powers  present. 

Examination. — ^Well  nourished  man  with  lips  of  good  color.  Heart, 
lungs,  abdomen,  and  genitalia  negative. 


Fig.  40  a. 

Rectal. — The  prostate  is  considerably  and  equilaterally  enlarged,  about 
the  size  of  a  small  orange.  Smooth,  rounded,  elastic  but  not  soft.  The 
seminal  vesicles  are  not  palpable. 

Cystoscopic. — A  small  coude  catheter  passes  with  ease  withdrawing  75 
cc.  residual  urine.  The  bladder  capacity  is  340  cc.  The  cystoscope  shows 
a  slight  intravesical  enlargement  of  the  lateral  lobes  joined  by  a  small  me- 
dian bar.  No  calculus  seen.  Examination  unsatisfactory  on  account  of 
hemorrhage. 

Urinalysis. — 1020,  neutral,  no  sugar,  no  albumin,  microscopically,  pus 
cells. 

Preliminary  treatment  for  four  weeks,  catheterization  and  irrigation  of 
bladder.  During  this  period  had  complete  retention  of  urine  several  times 
and  catheter  withdrew  500  cc.  of  urine. 

Operation,  January  10,  1902. — .Ether.  Perineal  prostatectomy.  This  is 
the  first  case  in  which  an  attempt  was  made  to  preserve  the  ejaculatory 
ducts  by  means  of  bilateral  capsular  incisions.  The  lateral  lobes  were 
enucleated,  and  the  median  bar  was  removed  in  two  pieces  through  the 
lateral  cavities.  The  incisions  were  made  very  superficially,  and  it  was 
found  very  difficult  to  separate  the  lateral  lobes  from  the  urethra.  The 
ejaculatory  bridge,  however,  was  not  very  badly  torn  and  none  of  the 
mucous  membrane  of  the  urethra  was  removed.  The  original  single  blade 
prostatic  tractor  was  used  and,  although  it  had  been  provided  with  a 
"barb"    (see   Fig.    40a),   after   the   lateral    lobes   had   been    removed   the 


study  of  llf5  Cases  of  'Perineal  Prostatectomy.  151 

instrument  slipped  out  of  the  bladder  and  was  very  difficult  to  introduce 
again.  The  need  of  an  instrument  which  would  not  slip  out  was  forcibly 
impressed  upon  us  and  led  to  the  construction  of  the  double-bladed 
rotating  tractor.  The  lateral  cavities  were  packed  with  gauze  and  a  single 
large  drainage  tube  was  placed  through  the  perineum  into  the  bladder. 
Patient  stood  operation  well,  pulse  at  end  80,  infusion  on  return  to  ward. 
Convalescence. — About  12  hours  later  the  drainage  tubes  be- 
came plugged  with  a  clot  of  blood  and  were  accidentally  removed 
by  the  orderly.  The  interne  experienced  a  great  deal  of  difficulty 
getting  the  tube  back  into  the  bladder  and  considerable  hem- 
orrhage occurred.  On  the  fourth  day  the  drainage  tube  was  finally  re- 
moved. On  the  seventh  day  the  patient  was  allowed  to  get  up  in  a  wheel- 
chair, but  on  the  fourteenth  acute  epididymitis  set  in  and  went  on  to 
abscess  formation,  which  was  incised  five  weeks  after  the  operation.  Dur- 
ing the  seventh  week  the  patient  passed  a  small  calculus,  and  after  that 
seven  or  eight  others.  During  the  third  week  after  the  operation  most  of 
the  urine  was  coming  through  the  urethra.  The  temperature  reached  102° 
on  the  fourth  day,  but  after  the  seventh  day  remained  normal  until  March 
1,  when  temperature  rose  to  103.8°  followed  by  a  urethral  chill. 

March  8,  1903. — A  catheter  passes  with  ease  and  there  is  no  residual 
urine.  The  bladder  capacity  is  3-50  cc.  The  cystoscope  shows  a  small  mass 
of  granulation  tissue  in  the  anterior  portion  of  the  trigone  just  back  of 
the  median  portion  of  the  prostate,  and  on  top  of  this  is  a  calculus  of 
small  size,  but  firmly  fastened  to  it.  There  is  no  free  calculus  in  the 
bladder.  The  prostatic  margin  is  irregular,  but  there  is  no  evidence  of 
prostatic  hypertrophy.  The  perineal  fistula  is  very  small,  only  a  few 
drops  escape  through  it  and  the  patient  is  able  to  retain  his  urine  well. 
An  effort  was  made  to  dislodge  the  calculus  with  the  cystoscope. 

March  25,  1903. — Two  calculi  have  been  passed  since  the  cystoscopic  ex- 
amination. The  cystoscope  shows  no  calculi  present  and  the  mass  of  gran- 
ulation on  which  one  was  incrusted  has  entirely  disappeared.  In  the  an- 
terior portion  of  the  prostate  several  large  granulations  are  seen.  With 
the  finger  in  the  rectum  and  cystoscope  in  the  urethra  the  amount  of  tis- 
sue between  the  two  is  less  than  normal. 

March  27,  1903. — The  patient  is  discharged.  Condition  is  excellent. 
Both  epididymes  are  indurated,  small  fistula  is  still  present.  The  patient 
voids  at  intervals  of  five  hours  with  a  large  stream  and  perfect  control. 

Letter,  January  20,  1904- — The  fistula  closed  four  months  after  the  op- 
eration. I  now  urinate  once  during  the  night  and  at  intervals  of  three  to 
four  hours  during  the  day.  I  have  not  used  a  catheter  and  urination  is 
satisfactory.  Occasionally  I  have  a  slight  pain  in  the  bladder.  I  have 
erections  once  or  twice  a  week  and  have  sexual  intercourse. 

June  4j  1904.  Letter.  I  can  hold  my  urine  six  to  eight  hours  at  night 
and  four  hours  during  the  day  .  Urination  is  normal,  but  I  have  a  slight 
pain  occasionally  in  the  bladder.  I  have  erections  and  intercourse,  but 
ejaculations  are  not  normal. 


153  Hugh  H.  Young. 

January  IS,  1905. — I  am  cured  with  the  exception  of  a  slight  pain  which 
I  occasionally  have  in  the  bladder.  I  have  had  no  instrumentation  since 
my  discharge.  I  urinate  once  at  night  and  three  to  six  times  in  the  day, 
and  pass  large  amounts.  Erections  and  intercourse  are  present,  but  are 
not  as  satisfactory  as  before  operation.     My  general  health  is  excellent. 

December  7,  1905. — Letter  from  wife.  My  husband  died  September  12, 
1905,  of  catarrh  of  the  stomach. 

Case  5. — Moderate  enlargement  of  lateral  lobes.  Pain  suggesting  renal 
calculus.    Cure.    Followed  20  months. 

No.  289,    J.  S.  S.,  age  65,  married,  admitted  January  14,  1903. 

Complaint. — •■"  Bladder  trouble." 

Gonorrhcea  in  his  youth  was  cured  without  complications. 

Present  illness  began  15  months  ago  with  pain  at  the  beginning  of  uri- 
nation which  radiated  from  his  bladder  upward  along  the  right  side  and 
apparently  terminated  in  his  right  kidney.  The  pain  was  very  severe  in 
character,  lasting  about  three  minutes,  at  no  time  radiated  to  the  penis 
and  was  not  associated  with  hematuria.  Irrigations  of  the  bladder  seemed 
to  relieve  him.  During  the  next  month  every  time  he  urinated  he  had  a 
pain  which  seemed  to  start  from  a  point  deep  down  in  the  pelvis,  and 
from  there  traveled  upward  to  beneath  ribs  on  the  right  side.  There  was 
no  pain  in  the  testicles,  thigh,  bladder  or  penis.  Urination  was  markedly 
frequent  and  the  amounts  voided  small.  Considerable  diflBculty  in  starting 
the  flow  of  urine.  He  then  went  to  a  mineral  springs  and  the  pain  dis- 
appeared. In  August,  1902,  a  physician  pronounced  his  case  catarrh  of 
the  bladder  and  gave  him  a  catheter  to  use.  In  November  he  went  to  an- 
other physician  who  writes  as  follows:  His  urine  was  filled  with  pus,  the 
prostate  was  inflamed  and  tender.  A  catheter  found  10  ounces  of  residual 
urine.  I  treated  him  by  irrigations,  massage  of  the  prostate,  instillations. 
He  now  has  a  residual  of  four  ounces.  Urine  is  voided  more  easily  and 
his  general  health  is  better.    There  is  still  pain  in  the  region  of  the  bladder. 

S.  P. — There  is  considerable  hesitation  at  the  beginning  of  urination, 
and  a  pain  at  the  end  which  is  dull  in  character  and  occasionally  travels 
upward  from  the  bladder  towards  the  right  kidney,  but  is  not  nearly  so 
severe  as  at  onset.  There  is  no  great  increase  in  the  frequency  of  urina- 
tion, and  he  often  only  gets  up  once  during  the  night. 

Sexual  powers. — .Sexual  desire  has  been  absent  for  the  past  six  months, 
previous  to  which  coitus  was  normal. 

Examination. — The  patient  looks  well.  Lips  of  good  color.  Heart  and 
lungs  negative.  There  is  no  tenderness  in  the  region  of  either  kidney  and 
no  enlargements  to  be  made  out. 

Rectal. — ^The  prostate  is  moderately  but  symmetrically  enlarged,  and  the 
median  furrow  is  broad  and  shallow.  The  surface  is  slightly  irregular 
towards  the  upper  end,  but  the  consistence  is  generally  elastic.  The  semi- 
nal vesicles  are  not  indurated. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  160  cc.  resid- 
ual urine.     The  bladder  capacity  is  700  cc.     The  cystoscope  shows  two 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  153 

fairly  large  intravesical  enlargements  of  the  lateral  lobes  with  a  deep  sul- 
cus in  front  and  a  deep  sulcus  behind.  A  small  transverse  fold  of  mu- 
cous membrane  was  seen  in  the  median  portion  of  the  prostate  connecting 
two  lateral  enlargements.  The  bladder  is  remarkably  trabeculated  with 
numerous  small  pouches. 

Urinalysis. — Cloudy,  acid,  1010,  albumin  in  small  amount.  Urea  23-G. 
per  liter.    Microscopically,  pus  cells,  a  few  hyaline  casts  and  bacilli. 

Operation,  ■January  20,  1903. — Ether.  Perineal  prostatectomy.  The  tech- 
nique which  is  now  employed  was  used  in  this  case  with  the  exception  that 
the  single-bladed  tractor  was  used.  The  bilateral  capsular  incisions  which 
have  been  used  with  the  idea  of  preserving  the  floor  of  the  urethra  and 
ejaculatory  ducts  were  made.  The  right  lateral  lobe  came  away  in  one 
piece,  and  measured  2x3x3  cm.  The  left  lateral  lobe  came  away  in  three 
pieces  which  together  form  a  mass  larger  than  the  right  lobe.  The  tractor 
was  then  withdrawn  and  the  finger  inserted  and  showed  no  enlargement 
of  the  median  portion  of  the  prostate.  The  entire  urethra  and  ejaculatory 
ducts  were  preserved  intact.  The  tractor  employed  in  this  case  was  the 
single-bladed  tractor  with  a  shoulder  across  the  front  of  the  blade  at  its 
end.  The  same  difficulty  was  experienced  from  its  slipping  out  of  the 
bladder  when  one  lobe  had  been  removed.  Two  catheters  were  fastened 
together  and  placed  in  the  bladder  for  drainage.  This  was  done  because 
in  previous  cases  difficulty  had  been  experienced  on  account  of  the  single 
drainage  tube  becoming  plugged  with  blood.  Gauze  packs  were  placed  two 
in  the  capsule  of  the  prostate  and  two  behind  it,  the  latter  to  be  removed 
last  and  thus  obliterate  the  cavity  left  after  removal  of  the  first.  Levator 
muscles  were  brought  together  with  several  catgut  sutures  and  the  skin 
wound  partially  closed. 

Convalescence. — The  patient  stood  the  operation  well,  but  the  pulse  at 
the  end  was  very  rapid,  140  to  the  minute.  He  was  infused  on  the  table 
and  half  an  hour  after  the  operation  his  pulse  had  fallen  to  88,  and  his  con- 
dition was  excellent.  The  highest  temperature  was  100.8°  on  the  day 
after  the  operation.  After  four  days  it  was  normal.  Continuous  irrigation 
was  maintained  for  seven  days  when  the  tubes  and  gauze  were  removed. 
Urine  began  to  come  through  the  anterior  urethra  on  the  14th  day.  On  the 
12th  day  the  patient  began  to  walk.  The  perineal  fistula  closed  finally  on 
the  18th  day,  and  the  patient  was  discharged  on  the  21st  day.  At  that 
time  he  was  voiding  urine  freely  at  intervals  of  five  hours  and  felt  per- 
fectly well. 

March  15,  1903. — ^I  void  urine  naturally  at  intervals  of  from  six  to  eight 
hours.    Have  a  slight  pain  in  the  groin,  otherwise  feel  perfectly  well. 

Sept.  28,  1903. — Letter  from  physician.  The  patient  is  perfectly  well, 
very  seldom  rises  at  night  to  urinate.  He  has  complete  control,  no 
dribbling. 

October  6,  1903. — Letter.  I  do  not  get  up  at  all  to  urinate  at  night,  am 
free  from  pain.     I  have  had  no  erections  as  yet. 

May  20,  1904- — I  void  urine  naturally  at  intervals  of  seven  or  eight  hours 


154  Hugh  H.  Young. 

at  night,  four  or  five  during  the  day.     I  suffer  no  pain.     Urination  is  nor- 
mal.    Erections  have  returned. 

March  9,  1905. — >Letter  from  physician.  The  patient  died  September  9, 
1904.  Previous  to  his  death  urination  was  normal.  He  seldom  had  to  rise 
during  the  night  to  urinate.  There  was  about  15  cc.  residual  urine,  and 
the  bladder  capacity  was  over  500  cc.  He  had  been  entirely  free  from  all 
pain  for  some  time.  Erections  and  sexual  powers  were  normal,  and  his 
ejaculations  were  satisfactory.  He  died  suddenly  while  sitting  in  a  chair 
from  angina  pectoris. 

Case  6. — Large  hypertrophy.  Catheter  life  eight  years.  No  stone. 
Cured. 

No.  341.  S.  T.  A.,  age  70,  single,  admitted  February  28,  1903,  complain- 
ing of  obstruction  to  urination,  and  catheterism  for  eight  years.  He  has 
never  had  gonorrhoea  nor  any  previous  urinary  trouble. 

P.  I. — Onset  15  years  ago  with  slight  frequency  and  difficulty  of  urina- 
tion which  grew  gradually  worse  during  the  next  seven  years  until  finally 
he  was  urinating  from  five  to  eight  times  during  the  night.  He  then  con- 
sulted a  physician  who  catheterized  him  and  found  a  large  quantity  of  re- 
sidual urine.  Since  then  the  patient  has  never  been  able  to  void  urine 
naturally  and  has  catheterized  himself  three  to  four  times  a  day. 

8.  P. — The  patient  is  using  a  catheter  three  times  a  day,  and  is  unable 
to  void  any  urine  naturally.  Occasionally  he  suffers  a  slight  pain  in  the 
rectum,  and  urethra  and  sometimes  catheterization  causes  considerable 
hemorrhage.    Erections  have  been  absent  for  five  years. 

Examination. — Lungs  negative.  Heart:  An  aortic  insufficiency  is  pres- 
ent, but  no  dilatation  of  the  heart.  Abdomen  negative.  The  prostate  by 
rectum  is  considerably  hypertrophied,  the  left  lobe  larger  than  the  right. 
The  contour  is  rounded,  surface  smooth,  consistence  elastic,  no  induration 
present. 

Cystoscopic  examinatioii. — The  patient  is  unable  to  void  urine.  A  soft 
rubber  catheter  passes  with  ease,  and  the  bladder  is  easily  washed  clean. 
Examination  of  the  prostatic  orifice  shows  a  moderate-sized  median  bar,  a 
considerable  intravesical  hypertrophy  of  the  left  lateral  lobe  attached 
to  which  is  a  fairly  large  anterior  lobe.  The  right  lateral  lobe  is 
not  intravesically  enlarged.  There  is  considerable  trabeculation  of  the 
bladder  wall,  chronic  cystitis  of  moderate  degree.  No  calculus  present. 
The  urine  is  acid,  specific  gravity  1019,  no  sugar,  no  albumin.  Microscop- 
ically, pus  cells,  bacilli  and  cocci.     Urea  .024  G.  per  1  cc. 

Preliminary  treatment  for  10  days,  during  which  the  patient  was  cath- 
eterized, the  bladder  was  irrigated,  and  urotropin  administered  internally. 
Study  of  the  urine  showed  no  evidence  of  kidney  disease,  and  although  the 
patient  was  a  rather  weak  old  man,  prostatectomy  was  decided  upon. 

Operation,  March  10,  1903. — (Ether.  Perineal  prostatectomy.  Enucleation 
of  a  small  right  lateral  lobe,  and  a  very  large  left  lateral  lobe  with  the 
median  bar  and  anterior  lobe  attached  to  it.  The  regular  technique  was 
followed.     The  ejaculatory  ducts  and  urethra  were  preserved,  and  only  a 


study  of  IJf-o  Cases  of  ■Perineal  Prostatectomy.  155 

small  area  of  mucous  membrane  covering  the  anterior  lobe  was  removed. 
The  wound  was  closed  as  usual.  The  levators  were  not  approximated. 
Saline  infusion  of  1200  cc.  of  salt  solution  on  the  table.  Double  catheter 
drainage  provided  through  perineal  wound.  There  was  only  a  moderate 
amount  of  hemorrhage  and  the  patient  stood  the  operation  well. 

Convalescence. — The  drainage  tubes  became  plugged  with  a  blood  clot 
and  had  to  be  removed  two  hours  after  the  operation.  Evacuation  of 
clots  consumed  considerable  time  and  the  patient  was  quite  shocked  for 
a  short  while.  The  tubes  Avere  removed  on  the  seventh  day.  On  the  21st 
day  the  urine  still  came  entirely  through  the  perineum  and  a  retained 
urethral  catheter  was  applied.  The  perineal  fistula  did  not  close  com- 
pletely until  two  months  after  the  operation.     No  epididymitis. 

Examination,  May  29,  1903. —  (Two  and  one-half  months  after  operation). 
The  catheter  has  not  been  required  since  operation.  Urine  is  voided  in  a 
large  stream  at  intervals  of  three  hours.  There  is  no  incontinence,  no  hesi- 
tation, and  perfect  control.  The  fistula  is  closed,  his  strength  is  good. 
The  catheter  passes  with  ease.  Residual  urine  25  cc.  Bladder  capacity  240 
cc.     Discharged  on  the  83d  day. 

Remarh. — The  result  is  excellent,  but  the  patient  is  advised  to  dilate 
the  bladder  by  hydraulic  pressure  to  increase  its  capacity  and  the  inter- 
val of  urination. 

Final  note. — The  patient  remained  well  for  five  months.  He  then  died 
suddenly  of  some  intercurrent  disease,  the  nature  of  which  was  not  clear. 
His  physician  reports  that  he  was  entirely  cured  of  his  prostatic  trouble. 

PatJiological  report. — Specimen,  G.  U.  62.  The  prostate  has  been  removed 
in  two  pieces  and  weighs  70  grams.  The  right  lateral  lobe  weighs  20 
grams,  and  the  left  lateral  50  grams.  The  inner  portion  of  the  left  lateral 
lobe  has  two  large  lobules  separated  by  deep  fissure,  and  is  probably  the 
median  and  anterior  portion  of  the  prostate.  The  consistence  of  the  lobes 
is  elastic  and  they  show  numerous  small  spheroids  bound  together  by 
connective  tissue.  There  is  no  induration  nor  euggestion  of  malignancy. 
There  are  no  mucous  membrane  nor  ejaculatory  ducts  removed. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one,  the  various  acini  being  separated  by  fair  amounts  of  stroma.  There 
seems  to  be  but  slight  tendency  to  arrangement  of  the  acini  in  spheroids 
nor  do  the  lumina  of  the  acini  present  the  same  complexity  of  outline 
which  one  so  frequently  sees.  There  are  very  few  intraacinous  projec- 
tions, and  there  is  present  very  little  dilatation.  The  stroma  contains  more 
connective  tissue  than  muscle,  but  the  muscle  element  is  fairly  abundant. 
The  blood  vessels  show  a  moderate  degree  of  arteriosclerosis.  There  are 
some  areas  of  prostatitis  present. 

Case  7. — Moderate  hypertrophy  of  median  and  lateral  lodes.  Catheter- 
ism.  Complication — gauze  pack  not  removed.  Second  operation  10  months 
later.    Removal  of  gauze.    Cure.    Followed  3S  months. 

No.  340.     W.  S.  O.,  age  58,  married,  admitted  February  26,  1903. 

Complaint. — <"  Prostatic  hypertrophy." 

No  history  of  gonorrhoea. 


156  Hugh  H.  Young. 

Present  illness  began  eight  years  ago  with  slight  difficulty  of  urination. 
In  February,  1S96,  acute  retention  of  urine  came  on  and  he  had  to  be 
catheterized,  and  two  months  later  had  to  be  catheterized  again  for  the 
same  reason.  Since  then  the  patient  has  catheterized  himself  every  day. 
In  September,  1S96,  both  epididymes  became  inflamed.  During  the  past 
seven  years,  in  which  he  has  used  a  catheter  at  bed  time,  he  has  had  as  a 
rule  very  little  discomfort  with  the  exception  of  epididymitis  and  occa- 
sional hematuria  and  fever.    His  general  health  has  remained  good. 

S'.  P. — iThe  patient  catheterizes  himself  at  bed  time,  and  during  the  day 
is  able  to  void  small  amounts. 

Sexual  powers. — Erections  are  apparently  normal,  but  sexual  powers 
have  been  slightly  impaired. 

Examination. — The  patient  is  a  healthy  looking  man.  Chest  and  abdo- 
men negative. 

Rectal  examination. — 'The  prostate  is  moderately  hypertrophied,  fairly 
hard,  slightly  irregular,  but  not  nodular.  The  median  furrow  and  notch 
are  obliterated  and  the  seminal  vesicles  are  not  palpable. 

Urinalysis. — Cloudy,  slightly  acid,  sp.  gr.  1010,  albumin  in  slight  amount, 
no  sugar.  Microscopically,  pus  cells  in  moderate  number  and  bacilli. 
Urea  9  grams  per  liter. 

Cystoseopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
140  cc.  residual  urine.  The  bladder  is  apparently  large  and  of  good  ton- 
icity. The  cystoscope  shows  a  moderate  intravesical  enlargement  of  both 
lateral  lobes  and  a  rounded  median  bar  continuous  with  the  left  lateral 
lobe,  but  separated  from  the  right  lateral  lobe  by  an  intervening  sulcus. 
The  bladder  is  slightly  inflamed,  moderately  trabeculated,  with  several 
small  cellules  present.  The  right  ureter  can  be  seen  and  appears  normal; 
the  left  cannot  be  seen  on  account  of  the  median  bar. 

Operation,  March  2,  1903. — Perineal  prostatectomy  by  the  usual  tech- 
nique. The  lateral  lobes  which  were  moderately  enlarged  were  removed 
each  in  one  piece.  The  median  lobe  was  then  drawn  into  the  left  lateral 
cavity  and  easily  enucleated.  The  floor  of  the  urethra  and  ejaculatory 
ducts  were  preserved  and  the  wound  was  closed  with  double  tube  drainage 
and  light  gauze  packs  for  the  lateral  cavities. 

Convalescence. — The  patient  reacted  well  from  the  operation.  The  tem- 
perature reached  102°  on  the  gecond  and  third  days,  but  after  that  it  was 
practically  normal.  The  gauze  packing  was  gradually  removed,  beginning 
on  the  third  and  completed  on  the  sixth  day.  Continuous  irrigation  of 
the  bladder  was  kept  up  for  nine  days  and  the  tubes  then  removed.  For 
one  day  all  of  the  urine  came  through  the  perineal  wound.  A  catheter 
was  then  inserted  through  the  urethra,  and  maintained  there  for  four  days. 
After  that  the  patient  voided  partly  through  the  penis  and  partly  through 
the  wound.  The  patient  was  up  in  a  wheel-chair  on  the  twelfth  day  and 
was  walking  during  the  third  week.  He  was  discharged  on  the  twentieth 
day.  At  that  time  he  was  voiding  urine  at  intervals  of  four  hours,  had 
no  inconvenience,  only  a  small  amount  of  urine  came  through  the  perineal 
fistula.    The  fistula  finally  closed  one  month  after  the  operation. 


study  of  Ho  Cases  of  •Perineal  Prostatectomy.  157 

May  1,  1903. — Perineal  wound  lias  been  closed  for  a  month.  The  patient 
voids  urine  every  three  or  four  hours,  suffers  no  pain,  and  feels  well. 
There  has  been  no  incontinence,  but  he  has  had  a  urethral  discharge  and 
once  or  twice  a  small  amount  of  blood  at  the  meatus.  Partial  erections 
have  occurred. 

Examination. — The  perineal  wound  has  healed.  A  catheter  passes 
with  ease  and  finds  no  residual  urine.  The  bladder  capacity  is  300  cc.  The 
urine  contains  considerable  pus  in  the  first  and  third  glass,  but  the  second 
is  practically  clear. 

October  8,  1903. — 'A  urethral  discharge  persisted  during  the  summer,  and 
in  August  he  began  to  suffer  pain  in  the  perineum,  an  abscess  developed 
and  was  incised  in  Mexico.  Since  then  perineal  fistula  has  never  closed 
and  there  has  been  a  considerable  discharge  from  the  meatus  and  from 
the  fistula.  There  has  also  been  considerable  hemorrhage  at  times,  but  al- 
ways with  the  first  urine.  A  catheter  passes  with  ease  and  shows  10  cc. 
residual  urine,  there  is  no  stricture  present.  The  cystoscope  shows  a 
slightly  irregular  prostatic  margin,  but  no  evidence  of  prostatic  enlarge- 
ment or  obstruction. 

January  11.  1904- — The  fistula  persists.  Rectal  examination  shows  a 
small  oval  mass  about  the  size  of  a  normal  prostate  in  the  region  of  the 
prostate.  Examination  causes  blood  to  escape  through  the  fistula.  Op- 
eration upon  the  fistula  is  advised. 

Operation,  Jamiary  15,  1904- — Ether.  The  perineal  fistula  was  excised 
and  found  to  lead  into  the  left  lateral  cavity  of  the  prostate  where  a  con- 
siderable piece  of  gauze  forming  a  mass  about  3  cm.  in  diameter  was 
found  imbedded.  It  was  extracted  without  difficulty,  and  the  cavity  thor- 
oughly curetted.  The  bulbous  urethra  was  opened  and  a  retention  catheter 
fastened  to  the  skin  by  silk  sutures. 

Convalescence. — The  patient  reacted  well.  The  retention  catheter  was 
maintained  for  19  days.  At  that  time  the  posterior  fistula  had  closed  tight. 
Since  the  removal  of  the  catheter  the  bulbar  urethrotomy  wound  has 
healed  slowly,  and  to-day,  four  weeks  after  the  operation,  all  the  urine 
passes  through  the  meatus. 

June  17,  1904- — The  patient  is  able  to  retain  urine  for  five  or  six  hours, 
and  urination  is  normal.  His  sexual  powers  have  gradually  improved. 
Erections  are  fairly  good,  but  he  has  not  attempted  intercourse. 

Fe'bruary  1,  1905. — Letter.  I  void  urine  naturally,  do  not  get  up  at  night 
and  consider  myself  cured. 

November  30,  1905. — ^Letter.  I  void  urine  naturally  once  at  night  and 
twice  during  the  day  and  large  amounts  at  a  time.  I  have  no  pain,  no  fis- 
tula and  consider  myself  cured.  Erections  are  fair  and  sexual  intercourse 
fairly  satisfactory.    My  health  is  excellent. 

May  8,  1906. — Letter.  I  void  urine  naturally,  and  often  do  not  urinate 
at  all  during  the  night.  I  have  no  pain.  I  have  erections  and  sexual  in- 
tercourse, but  the  erections  are  slightly  imperfect.  My  general  health  is 
excellent,  and  I  consider  myself  cured. 


T 


158  Hugh  H.  Young. 

Pathological  report. — Specimen,  G.  U.  64.  The  specimen  consists  of  two 
pieces,  the  median  and  lateral  lobes  and  weighs  30  grams.  The  left  lobe 
measures  4.5x3.5x2  cm.  The  right  lobe  4.5x3x2  cm.,  the  median 
4  X  2.5  X  1.5  cm.  No  mucous  membrane  or  ejaculatory  ducts  have  been 
removed.  The  surface  shows  numerous  small  lobules  and  spheroids,  and 
is  elastic  in  consistency. 

Microscopic  examination. — The  hypertrophy  is  of  a  mixed  type,  in  some 
areas  glandular,  in  others  fibro-muscular.  Some  formation  of  spheroids, 
the  spheroidal  areas  being  glandular.  The  acini  within  these  spheroids 
present  the  usual  intra-acinous  off-shoots,  often  of  papillomatous  type. 
The  stroma  contains  a  large  amount  of  muscle,  which  is  equal  to,  if  not 
in  excess  of  the  connective  tissue.     The  blood  vessels  seem  about  normal. 

Case  8. — Chronic  prostatitis  with  median  Tjar  formation.  Complete  re- 
tention of  urine.  Severe  cystitis  and  vesical  irritability.  Operative  result, 
iyiiproved. 

No.  364.     P.  F.  E.,  age  45,  ma,rried,  admitted  November  4,  1902. 

Complaint. — "  Bladder  trouble  which  came  on  after  typhoid  fever." 

He  never  had  gonorrhoea. 

Present  illness. — ^Two  years  ago  the  patient  had  typhoid  fever  and  re- 
quired catheterization.  Since  then  the  catheter  has  been  necessary  most 
of  the  time,  and  of  late  he  has  had  to  use  it  very  frequently,  generally 
every  two  hours  and  sometimes  as  often  as  every  half  hour.  On  admission 
he  was  using  the  catheter  from  10  to  18  times  at  night,  and  would  often 
experience  great  difficulty  in  introducing  it.  He  suffered  severe  pain  In 
the  bladder  which  was  markedly  contracted,  and  has  lost  a  great  deal 
of  weight.  He  has  had  no  sexual  intercourse  for  over  two  years,  but  has 
had  erections  frequently  and  nocturnal  pollutions  occasionally. 

Examination. — The  patient  is  a  weak-looking,  nervous  man.  Heart, 
lungs  and  abdomen  are  negative.  A  soft  rubber  catheter  meets  with  an 
impassable  obstruction  21  cm.  from  the  meatus.  A  silver  catheter  passes 
with  ease  and  withdraws  420  cc.  residual  urine. 

Rectal  examination. — The  prostate  is  only  slightly  enlarged,  indurated 
and  continuous  with  the  seminal  vesicles  which  are  also  indurated  and 
adherent  to  surrounding  structures.  Running  from  one  seminal  vesicle 
to  the  other  is  a  connecting  mass  of  indurated  tissue.  The  picture  is  that 
of  chronic  prostatitis  and  seminal  vesiculitis. 

Cystoscopic  examination. — (The  bladder  is  very  irritable  and  appears  to 
be  contracted.  The  cystoscope  shows  a  markedly  inflamed,  trabeculated 
bladder.  The  lateral  lobes  are  not  at  all  enlarged,  but  there  is  a  small 
median  bar  present. 

Treatment. — At  first  the  patient  was  catheterized  four  times  a  day  and 
the  bladder  irrigated  with  boric  acid.  Under  this  treatment  he  improved 
considerably,  and  after  53  days  in  the  hospital  he  returned  home  able  to 
void  his  urine  without  a  catheter.  Very  soon  the  vesical  irritability  re- 
turned and  catheterization   again  became  necessary. 

On  second  admission,  February  2,  1903,  he  was  using  a  catheter  several 


study  of  lJf5  Cases  of  •Perineal  Prostatectomy.  159 

times  a  day,  and  was  able  to  void  only  wittL  great  difficulty.  The  urine 
was  acid,  1018;  no  sugar;  albumin,  a  trace;  microscopically,  pus,  epithe- 
lium.    No  casts. 

February  22,  1903. — Cystoscopic  examination.  A  catheter  finds  250  cc. 
residual  urine.  The  cystoscope  shows  a  definite,  but  small,  median  bar, 
but  no  enlargement  of  the  lateral  lobes.  The  bladder  is  markedly  trabe- 
culated.  Numerous  pouches  and  small  diverticula  are  seen  in  the  region 
of  the  ureteral  orifices.  With  the  finger  in  the  rectum  and  cystoscope  in 
the  urethra  a  definite  increase  in  the  median  portion  of  the  prostate  is 
made  out. 

Operation,  March  5,  1903. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  enucleated,  and  when  removed  were 
found  to  be  very  little  enlarged.  No  note  is  made  as  to  the  median  lobe, 
but  this  was  apparently  left  behind,  as  it  was  impossible  to  get  it  to  present 
into  one  of  the  lateral  cavities.  (This  was  one  of  the  early  operations  and 
a  different  technique  would  now  be  used.)  The  wound  was  closed  as 
usual  with  gauze  drainage  for  the  lateral  cavities  and  double  tube  drain- 
age for  the  bladder.  Patient  stood  operation  well,  pulse  at  end  80.  Con- 
tinuous irrigation  was  kept  up  for  10  days. 

Convalescence. — Satisfactory.  The  temperature  did  not  rise  above  100^ 
and  bis  condition  was  always  good.  The  drainage  tubes  were  removed  on 
the  tenth  day,  and  on  the  sixteenth  day  a  retained  catheter  was  placed 
in  the  urethra  in  order  to  facilitate  closure  of  the  perineal  fistula.  He 
was  discharged  from  hospital  on  May  10,  his  general  condition  being  good, 
but  a  small  perineal  fistula  was  still  present. 

April  28,  1903. — The  perineal  fistula  persists,  and  probe  passes  directly 
into  the  urethra.    To-day  the  edges  are  freshened  up  with  scissors. 

May  5,  1903. — The  perineal  fistula  is  healed  except  for  a  small  opening. 
During  the  day  he  is  able  to  hold  his  urine  for  several  hours,  but  during 
the  night  there  is  occasional  incontinence.  His  general  condition  is  ex- 
cellent. 

May  25,  1903. — The  patient  got  up  once  last  night  to  urinate.  This 
morning  he  has  held  his  urine  for  four  hours.  He  voids  urine  easily  with- 
out hesitation  and  has  no  dribbling.  The  fistula  is  closed.  Silver  catheter 
passes  with  ease  and  finds  25  cc.  residual  urine  and  a  bladder  capacity 
of  350  cc. 

January  20.  190'). — Letter.  I  can  hold  my  urine  for  three  hours  during 
the  day,  but  have  to  arise  about  every  1%  hours  at  night.  The  fistula 
closed  three  months  after  the  operation.  I  still  suffer  pain  in  the  bladder 
and  my  urine  is  cloudy.     I  have  no  erections. 

May  22,  1904. — Letter.  I  void  urine  about  every  two  hours  during  the 
day  and  about  every  six  hours  during  the  night.  The  stream  is  small  and 
the  amount  of  urine  voided  about  125  cc.    I  have  never  used  a  catheter. 

November  30,  1905. — I  am  greatly  improved  by  the  operation,  but  have 
more  frequent  urination  during  the  night  than  I  have  during  the  day.     I 
do  not  use  a  catheter.    I  have  pain  in  the  back.    I  have  gained  in  weight. 
I  do  not  have  erections  any  more. 
Vol.  XIV.— 12. 


160  Hugh  H.  Young. 

May  Hi,  1906. — Letter.  The  wound  has  remained  healed  and  I  have  not 
used  a  catheter.  I  hold  my  urine  very  well  during  the  day,  but  not  very 
well  at  night.  The  amount  voided  is  not  regular.  If  I  overdo  myself  I 
suffer  some  pain.  I  have  no  erections.  My  general  health  is  only  fairly 
good.     I  have  gained  in  weight,  and  I  am  cured  in  some  ways. 

Case  9. — Moderate  enlargement  of  median  and  lateral  lobes..  SuprapuMc 
cystostomy  and  three  Bottini  operations  done  previously.  Perineal  pros- 
tatectomy. Cure.  Rectal  fistula.  Plastic  operation  to  close  it.  Cure. 
Followed  22  m,onths. 

No.  351.    J.  M.  L.,  age  63,  married,  admitted  March  11,  1903. 

Complaint. — "  Prostatic  obstruction.    Suprapubic  fistula." 

No  history  of  gonorrhoea. 

Present  illness  began  six  years  ago  with  slight  difficulty  and  increased 
frequency  of  urination.  In  1898,  the  difficulty  had  increased  greatly  and 
finally  complete  retention  of  urine  came  on  requiring  catheterization. 
After  that  the  catheter  was  used,  at  first  every  day,  but  after  that  more 
frequently,  and  after  1899  the  retention  of  urine  was  complete.  In  Octo- 
ber, 1902,  the  patient  suffered  great  pain,  tenesmus  and  catheterization  was 
necessary  about  every  hour.  On  October  28,  1902,  the  bladder  was  punc- 
tured with  a  large  trocar  and  canula,  and  a  small  soft  catheter  inserted 
through  the  canula  and  left  in  the  bladder  for  continuous  drainage.  On 
December  16,  1902,  a  Bottini  operation  was  performed  in  an  adjacent  city. 
Two  incisions  were  made,  both  lateral  with  a  negative  result.  On  January 
11  a  second  Bottini  operation  was  performed,  a  median  incision  214  cm. 
being  made.  Results  again  negative.  On  February  1,  1903,  a  third  Bot- 
tini, two  lateral  incisions  between  the  previous  lateral  and  median  cuts. 
Results  negative.  The  suprapubic  catheter  drainage  was  maintained  and 
the  patient  was  unable  to  void  urine. 

S.  P. — No  urine  is  voided  through  the  urethra,  but  all  escapes  through 
a  small  suprapubic  catheter  drain.  The  patient  suffers  constant  pain  in 
the  bladder  for  which  he  takes  morphine. 

Sexual  powers. — Normal;  erections  occurred  at  frequent  intervals 
up  to  the  time  of  the  first  Bottini  operation.  Since  then  has  had  no 
erections. 

Examination. — The  patient  is  well  developed.  General  condition  good. 
The  chest  abdomen  and  genitalia  are  negative.  There  is  a  direct  reduci- 
able  hernia  on  the  left  side.  There  is  a  small  suprapubic  sinus  in  which 
the  patient  wears  a  small  catheter. 

Rectal. — The  prostate  is  moderately  enlarged,  rounded,  elastic.  At  the 
upper  end  of  the  right  lobe  there  is  a  small  nodule,  but  the  seminal  vesi- 
cles are  negative. 

Urinalysis. — Moderately  cloudy,  acid,  1015,  albumin  in  slight  amount, 
pus  cells  and  bacteria  numerous.  Total  urine  in  24  hours,  1260  cc.  Total 
urea  G-22.7. 

Cystoscopic. — The  bladder  capacity  is  200  cc.  The  cystoscope  showed 
two  fairly  large  intravesically  hypertrophied  lateral  lobes  connected  by 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  161 

a  moderately  large  median  bar  without  intervening  sulci.  Two  depres- 
sions, probably  cystoscopic  cuts,  were  seen,  but  they  were  very  shallow. 
The  suprapubic  catheter  was  seen,  and  its  end  is  slightly  encrusted  with 
calcarious  salts.  There  is  no  calculus  in  the  bladder.  The  trigone  and 
ureters  could  not  be  seen. 

Operation,  March  19.  1903. — :Ether.    Perineal  prostatectomy  by  the  usual 
technique.     The  lateral  lobes  were  moderately  hypertrophied  and  easily 
enucleated    Along  with  the  left  lateral  lobe  the  median  bar  and  a  portion 
of  the  right  lateral  lobe  was  enucleated  in  one  piece  without  injuring  the 
urethra  or  the  ejaculatory  ducts.    The  entire  right  lateral  lobe  could  easily 
have  been  drawn  through  the  suburethral  cavity  made  by  the  freeing  of 
the  median  lobe  into  the  left  lateral  cavity  and  removed  in  one  piece  with 
the  median  and   left  lobe  had   the   operator   not  been   afraid   of  tearing 
the  ejaculatory  ducts.     The  wound   was   closed  with  double  tube   drain- 
age  and   light   packs   for   the   lateral   cavities.      The   superficial   perineal 
muscles  were  approximated  with  three  buried  sutures  of  catgut  (but  ap- 
parently the  levator  muscles  were  not  drawn  together  over  the  rectum). 
The  skin  wound  was  partially  closed  on  each  side  with  catgut.    The  patient 
was  infused  on  the  table.    He  stood  the  operation  well,  but  his  pulse  was 
quite  rapid,  140  at  the  end.     Continuous  irrigation  on  return  to  the  ward. 
Convalescence. — The  suprapubic  drainage  was  maintained.     There  was 
practically     no     rise     of     temperature     and     the     patient     convalesced 
well.       On     the     night     after     the     operation     an     assistant,     thinking 
the     hemorrhage      was      too      profuse,      packed      a     considerable      addi- 
tional    amount     of     gauze     into     the     perineal     wound,     and  none  of 
this  was  removed  until  the  sixth  day  when  the  perineal  tubes  and  most 
of   the   gauze   were    extracted.      Nine    days    after    the    operation    all    of 
the   stitches   were  removed   on   account  of   suppuration,   and   the   wound 
irrigated  and  repacked.    On  the  eleventh  day  a  catheter  was  placed  in  the 
suprapubic  sinus  for  drainage.     The  patient  then  complained  of  gas  es- 
caping through  the  perineal  wound  for  the  first  time.     Two  weeks  after 
the  operation  a  definite  rectal  fistula  was  discovered.    The  perineal  urinary 
fistula  closed  about  30  days  after  the  operation,  and  the  patient  was  dis- 
charged from  the  hospital  May  24,  66  days  after  the  operation.     At  that 
time  there  was  no  leakage  of  urine  through  the  perineum  or  into  the  rec- 
tum, and  the  suprapubic  fistula  had  closed.    There  was  a  very  fine  perineal- 
rectal  fistula  present  through  which  a  small  amount  of  gas  occasionally 
escaped.     His  general  health  was  excellent.     He  was  able  to  retain  urine 
for  two  and  one-half  hours,  but  still  suffered   pain.     A  catheter  passed 
easily  and  showed  no  residual  urine.     Bladder  capacity  was  400  cc. 

October  26,  1903. — The  patient  reports  that  the  communication  between 
the  perineum  and  the  rectum  has  never  closed.  In  July,  after  a  forcible 
urethral  irrigation,  urine  began  to  escape  during  micturition  through  the 
perineal  fistula.  Since  then  gas  has  occasionally  escaped  through  the  ure- 
thra, but  never  any  feces.  Urination  is  satisfactory,  at  intervals  of  six 
hours  at  night  and  three  to  four  hours  in  the  day. 
Examination.— A  small  perineal  fistula  is  present,  through  which  a  fine 


163  Hugh  H.  Young. 

probe  can  be  passed  into  the  rectum,  the  rectal  opening  being  about  3  cm. 
above  the  anus.  No  urine  escapes  into  the  rectum  and  only  a  few  drops 
through  the  perineal  fistula. 

Operation,  October  21,  1903. — iEther.  Closure  of  rectal  and  urethral  peri- 
neal fistula.  An  inverted  V  perineal  incision  was  made  in  the  site  of  the 
old  scar  and  the  fistulous  tract  excised.  Urethrotomy  of  the  anterior  por- 
tion of  the  bulbous  urethra  was  then  performed  and  the  tractor  inserted. 
The  opening  into  the  urethra  was  then  sutured  with  several  layers  of  cat- 
gut, and  after  that  the  rectum  was  closed  with  several  layers  of  inter- 
rupted catgut.  The  skin  wound  was  partially  closed  and  lightly  packed 
with  gauze  and  a  permanent  perineal  drainage  tube. 

Convalescence. — The  patient  reacted  well.  The  perineal  drainage  tube 
was  removed  after  eight  days,  after  that  urine  was  voided  freely  through 
the  Incision  for  several  days,  but  there  was  never  any  leakage  of  the  sut- 
ured urethral  wound.  The  rectal  wound  broke  down  on  the  seventh  day 
and  gas  and  feces  escaped  through  the  perineum  for  about  a  week,  and  he 
thinks  a  small  amount  of  gas  escaped  through  the  meatus.  Since  the  14th 
day  the  rectal  wound  has  remained  closed,  and  the  perineal  wound  has 
healed.    The  bulbar  urethrotomy  wound  has  been  closed  since  the  21st  day. 

Decemder  20,  1903. — Examination.  The  patient  voids  urine  at  intervals 
of  three  and  one-half  hours,  occasionally  six  hours.  Both  wounds  in  the 
perineum  are  solidly  healed  and  the  rectal  fistula  is  closed.  The  silver 
catheter  passes  easily  and  finds  10  cc.  residual  urine.  The  urine  is  acid, 
cloudy,  contains  pus  cells  and  bacilli  in  large  number. 

May  20,  190^. — Letter.  The  wounds  have  remained  healed,  and  I  void 
urine  at  intervals  of  five  or  six  hours  at  night  and  three  or  four  hours  in 
the  day,  about  one-half  pint  at  a  time.  I  have  a  slight  pain  in  the  urethra. 
I  have  had  no  erections. 

February  1,  1905. — (Letter.  I  void  urine  naturally  at  intervals  of  one 
to  two  hours  during  the  day  and  two  to  three  at  night.  The  amount  voided 
each  time  is  abundant.  I  suffer  some  pain  during  urination.  I  have 
not  had  erections.     My  general  health  is  very  good. 

The  patient  died  March  31,  1905.     Cause  of  death  not  stated. 

Pathological  report. — The  specimen  G.  U.  271,  consists  of  one  piece 
which  represents  the  left  lobe  of  the  prostate,  median  bar  and  a  portion 
of  the  right  lobe,  and  weighs  in  all  about  G-10.  The  portion  forming  the 
left  lateral  lobe  is  a  globular  mass  about  3  x  2.5  x  2  cm.  in  size.  The  me- 
dian portion  is  about  2  cm.  thick.  Only  a  small  portion  of  the  right 
lateral  lobe  has  been  removed,  being  a  mass  about  2  cm.  in  diameter  and 
.5  cm.  thick.  On  section  there  is  a  moderate  amount  of  stroma,  and  con- 
siderable dilatation  of  the  acini.  No  mucous  membrane,  no  ducts  re- 
moved. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with 
moderate  dilatation  of  the  acini.  The  acini  show  a  rather  unusually  large 
number  of  intraacinous  projections,  often  papillomatous  in  type.  These 
intraacinous  off-shoots  are  often  formed  of  pure  epithelium,  the  stroma  as 
yet  not  having  grown  into  them.    It  would  seem  that  the  epithelial  activity 


study  of  140  Cases  of  'PerineaJ  Prostatectomy.  163 

was  unusually  marked  wittLin  the  acini.  The  stroma  contains  a  large 
amount  of  muscle,  in  many  areas  being  considerably  in  excess  of  the  con- 
nective tissue.  Some  embryonic  tissue  formation  is  seen.  The  blood  ves- 
sels for  the  most  part  are  normal,  but  here  and  there  there  is  present  a 
moderate  degree  of  arteriosclerosis. 

Case  10. — Small  sclerotic  prostate.  Pain  and  great  irritation.  Con- 
tracted bladder.  Cured  of  obstruction.  Slight  contraction  remains.  Fol- 
lowed three  years. 

No.  398.     E.  J.  H.,  age  62,  admitted  May  1,  1903. 

Complaint. — "Frequency  of  urination." 

Gonorrhoea  at  the  age  of  28,  a  light  attack  lasting  only  three  days.  Pres- 
ent illness  began  about  seven  years  ago  with  frequency  of  urination  and 
burning  in  the  urethra  and  slight  difficulty.  After  that  intermittent  at- 
tacks of  irritation  and  frequency  every  few  weeks.  For  the  past  five  years 
has  had  a  continuous  pain  in  the  bladder  with  difficulty  and  frequency  of 
urination.  He  had  complete  retention  of  urination  in  January,  1903,  four 
months  ago  and  required  catheterization  twice. 

S.  P. — The  patient  urinates  five  times  during  the  night  and  about  as 
often  during  the  day.  During  urination  he  has  a  burning  pain  in  the  ure- 
thra, but  the  stream  is  small  and  slow.  He  has  suffered  so  severely  that 
he  has  been  unable  to  attend  to  business.  His  sexual  powers  were  good 
until  six  years  ago,  since  then  ejaculation  has  been  extremely  painful, 
and  he  has  ceased  having  coitus.  Nocturnal  emissions  cause  a  burning 
which  he  says  is  like  a  coal  of  fire.  His  general  health  is  rather  poor;  he 
is  extremely  nervous. 

Examination. — The  patient  is  fairly  well  nourished,  but  extremely  neu- 
rotic in  appearance.     The  chest  and  abdomen  are  negative. 

Rectal. — The  prostate  is  moderately  enlarged.  The  right  lobe  is  smooth, 
but  quite  hard.  The  left  lateral  lobe  is  smaller  than  the  right,  its  surface 
is  a  little  irregular,  two  or  three  nodules  being  present,  and  is  quite  in- 
durated. The  seminal  vesicles,  however,  cannot  be  palpated  and  are  evi- 
dently soft. 

Cystoseopic. — A  coude  catheter  passes  easily  and  finds  100  cc.  residual 
urine.  The  bladder  is  considerably  smaller  than  normal.  The  cystoscope 
shows  prostatic  enlargement  in  the  shape  of  a  collar  around  the  orifice. 
The  lateral  lobes  are  definitely  hypertrophied  with  a  definite  sulcus  be- 
tween them  in  front.  The  median  bar  is  slight,  and  there  were  no  sulci 
between  it  and  the  lateral  lobes.  The  ureters  and  much  of  the  trigone 
could  be  seen  behind  the  bar.  The  bladder  is  considerably  trabeculated, 
no  cystitis,  no  calculus.  "With  finger  in  rectum  and  cystoscope  in  urethra 
the  beak  could  be  felt,  and  there  is  a  moderate  increase  in  the  median 
portion  of  the  prostate  and  a  considerable  increase  in  the  urethtral  length. 

Urinalysis. — Clear  with  a  few  shreds  in  Lhe  first  glass  which  under  the 
microscope  are  found  to  be  pus  cells.  The  urine  is  neutral,  1010,  slight 
trace  of  albumin,     Urea  G-8  to  the  liter.     Microscopically  negative. 

Operation,  May  IS.  1903. — -Ether.     Perineal  prostatectomy  by  the  usual 


16-i  Hugh  H.  Young. 

technique.  The  lateral  lobes  were  only  moderately  hypertrophied,  were 
quite  adherent  and  removed  with  some  difficulty,  but  each  came  away  in 
one  piece  without  tearing  the  urethra  or  bladder,  and  measured  5I/2  x  3% 
X  3  cm.  Examination  of  the  median  portion  showed  that  it  was  only 
slightly  larger  than  normal,  and  it  was  thought  unnecessary  to  remove 
this.  The  wound  was  closed  as  usual  with  double  tube  drainage,  light 
packs  for  the  lateral  cavities,  and  continuous  irrigation  on  return  to  the 
ward.  The  patient  stood' the  operation  well.  The  pulse  at  the  end  was  104. 
Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
101.2  on  the  day  after  the  operation.  He  had  some  fever  for  the  four  suc- 
ceedings  days,  and  after  that  the  temperature  was  practically  normal.  The 
irrigation  was  continued  for  four  days  when  the  tubes  were  removed,  and 
the  gauze  was  removed  on  the  third  day.  Interval  urination  was  estab- 
lished early,  and  oh  the  eighth  day  two-thirds  of  the  urine  came  through 
the  anterior  urethra.  The  perineal  fistula  closed  on  the  14th  day  and  the 
patient  left  for  home  on  the  19th  day.  Urination  was  almost  normal,  no 
incontinence,  and  condition  excellent. 

November  3,  1903. — ^I  suffered  for  a  time  with  irritability  of  the  bladder, 
but  have  improved,  and  can  now  retain  urine  for  three  or  four  hours  and 
have  no  incontinence. 

November  28,  1903. — I  retain  urine  for  four  or  five  hours  during  the  day. 
At  night  I  sometimes  urinate  every  hour  and  always  after  having  drank  a 
good  deal  of  water. 

May  20,  1904. — I  void  urine  about  every  four  hours  during  the  day,  more 
frequently  at  night,  about  six  ounces  at  a  time,  do  not  use  a  catheter.  Uri- 
nation is  satisfactory.     I  have  no  erections. 

January  15,  1905. — I  void  urine  normally  and  have  no  pain,  about  six 
times  in  the  day  and  six  times  at  night,  about  six  ounces  at  a  time.  I 
have  no  erections. 

November  30,  1905. — The  wound  is  closed.  I  void  four  or  five  times 
during  the  day  and  about  the  same  number  of  times  at  night,  but  I  drink 
a  large  amount  of  lithia  water.  I  have  never  used  a  catheter  s'ince  the 
operation  and  consider  myself  cured.  I  have  no  erections.  My  health  is 
good. 

Case  11. — Very  large  hypertrophy  of  the  two  lateral  lobes.  No  median 
lobe  enlargement.  Complete  retention  of  urine  for  10  days.  Catheter 
withdrew  4500  cc.  urine.  Bottini  operation.  Relief  of  obstruction.  Fif- 
teen months  later  severe  hemorrhages.  Perineal  prostatectomy.  Cure. 
Followed  three  years. 

No.  173.^W.  F.  S.,  age  55,  single,  admitted  January  10,  1902. 

Complaint. — "  Complete  retention  of  urine." 

The  patient  had  gonorrhoea  twice  in  his  youth,  but  no  stricture  devel- 
oped. Present  illness  began  five  years  ago  with  slight  difficulty  in  urina- 
tion and  since  then  his  condition  has  gradually  grown  worse,  urination 
gradually  becoming  more  frequent  and  difficult.  Three  months  ago  large 
clots  of  blood  passed  with  the  urine.    On  January  1,  1902,  he  was  suddenly 


study  of  lJf.5  Cases  of  'Perineal  Prostateciomy.  1G5 

seized  with  pain  in  the  bladder  and  was  unable  to  void  urine.  His  phj^- 
sician  was  able  to  withdraw  only  a  small  amount  of  urine  with  the  cathe- 
ter. A  chill  followed  by  fever,  nausea  and  vomiting  came  on,  and  although 
he  was  able  to  void  but  little  urine  he  was  not  catheterized  again  until 
January  10.  He  was  then  seen  by  Dr.  Pancoast,  who  found  the  abdomen 
greatly  distended,  and  the  bladder  palpable  three  fingers'  breadths  above 
the  umbilicus.  A  catheter  was  introduced  with  difficulty  and  4500  cc.  of 
cloudy  urine  withdrawn.  The  patient  was  then  sent  to  the  Johns  Hop- 
kins Hospital,  where  the  following  notes  were  made.  "  The  patient  is 
fairly  nourished  and  mentally  clear.  His  tongue  is  dry  and  red,  his 
pulse  of  good  volume  and  tension  regular,  the  vessel  wall  considerably 
sclerosed.  Very  fine  rales  are  present  at  the  bases  of  both  lungs,  a  slight 
systolic  murmur  is  present  at  the  apex  of  the  heart  and  the  second  aortic 
is  accentuated.  The  lower  abdomen  is  full  (17  hours  after  catheterization 
by  Dr.  P.).  The  bladder  dullness  extends  two  fingers'  breadths  above 
the  umbilicus.  A  catheter  passes  with  ease  and  2800  cc.  of  urine  is  with- 
drawn.    Catheter  is  fixed  in  the  bladder  for  permanent  drainage." 

January  16,  1902. — The  patient  has  improved,  but  still  has  a  slight  tem- 
perature, but  the  urine  contains  pus,  and  the  bladder  is  irrigated  twice 
daily. 

February  1,  1902. — ^The  bladder  has  been  drained  by  permanent  catheter 
for  three  weeks,  and  the  patient's  condition  is  excellent.  The  prostate  is 
considerably  enlarged  in  both  lateral  lobes,  consistence  soft,  elastic,  smooth, 
seminal  vesicles  not  indurated. 

Cystoscopic  examination. — Although  the  patient  has  had  continuous  cath- 
eterization for  three  weeks,  the  bladder  capacity  is  very  large  and  the  ton- 
icity very  poor.  The  cystoscope  shows  two  large  intravesically  hypertro- 
phied  lateral  lobes,  the  bladder  wall  is  only  moderately  trabeculated,  and 
no  diverticula  are  present. 

Urine. — On  admission  the  analysis  showed  sp.  gr.  1010,  reaction  acid,  no 
sugar,  trace  of  albumin,  a  sediment  tinged  with  blood,  and  microscopically, 
pus,  red  blood  corpuscles,  hyaline  and  coarsely  granular  casts.  A  daily 
urine  chart  was  kept  and  the  amount  of  urine  was  always  large,  varying 
from  2160  cc.  to  4370  cc.  on  January  17.  Sp.  gr.  was  generally  about  1010, 
and  the  total  urea  varied  from  15  to  28  grams  in  24  hours.  Hyaline  and 
granular  casts  were  constantly  present. 

March  15,  1902. — During  the  past  six  weeks  the  patient  has  been  cathe- 
terized five  times  a  day.  He  is  unable  to  void  urine,  and  produces  from 
1600  to  2300  cc.  urine  daily.  The  urine  is  still  purulent  and  still  contains 
hyaline  casts,  no  granular  casts  seen.     His  general  condition  is  excellent. 

March  16,  1902. — Operation.  4%  cocaine  in  the  urethra.  Bottini  opera- 
tion. Three  cuts,  one  posterior,  2.8  cm.  long,  two  lateral  with  blade  No. 
3,  each  3  cm.  long.  There  was  very  little  hemorrhage  and  the  patient  suf- 
fered no  pain. 

Convalescence. — Immediately  following  the  operation  the  patient  began 
to  dribble  urine.  A  catheter  was  passed  during  the  evening  and  700  cc. 
urine  withdrawn. 


166  Hugh  H.  Young. 

March  17,  1902. — The  patient  has  been  voiding  all  day,  a  catheter  finds 
600  cc.  residual  urine.  There  has  been  no  chill  or  fever  following  the  op- 
eration. The  patient  was  out  of  bed  on  the  third  day,  and  he  was  dis- 
charged on  the  12th  day,  in  excellent  condition. 

June  21,  1902. — The  patient  is  in  excellent  condition.  Voids  urine  twp 
or  three  times  in  the  day  and  once  at  night,  about  500  cc.  at  a  time.  The 
urine  is  cloudy,  acid,  sp.  gr.  1018,  and  albumin,  pus  cells  and  bacilli  are 
present. 

July  19,  1902. — The  patient  voids  a  good  stream  and  does  not  get  up  at 
night. 

April  14,  1903. — About  10  days  ago  the  patient  began  to  have  hematuria, 
the  hemorrhage  was  very  severe  and  lasted  for  several  days.  The  urine 
is  now  free  from  blood.  A  catheter  passes  with  ease  and  finds  only  16  cc. 
residual  urine.  The  bladder  capacity  is  large  and  the  tonicity  is  good. 
The  cystoscope  shows  two  very  large  intravesically  hypertrophied  lateral 
lobes  with  only  a  small  fold  of  mucous  membrane  joining  them  in  the  me- 
dian portion.  It  was  impossible  to  find  the  point  from  which  the  bleeding 
came.  As  the  patient  is  otherwise  normal,  and  often  does  not  get  up  at 
all  at  night  to  urinate,  no  operation  is  advised. 

May  15,  1903. — The  patient  has  had  another  severe  hemorrhage  in  the 
bladder,  and  an  injection  of  adrenalin  is  required  this  morning  to  stop  it. 

May  16,  1903. — The  urine  is  again  clear.  General  condition  is  excellent. 
Voids  urine  in  a  large  stream  four  or  five  times  a  day,  and  has  apparently 
a  perfect  result  from  the  Bottini  operation  with  the  exception  that  when 
he  has  intercourse  no  semen  appears  at  the  meatus,  although  the  act  is 
otherwise  normal.  He  is  advised  to  have  perineal  prostatectomy  in  order 
to  remove  the  tremendous  prostate  and  relieve  him  of  the  dangerous  hem- 
orrhages. Rectal  examination  shows  the  prostate  to  be  very  large,  smooth 
and  soft.  The  lungs  are  negative.  There  is  a  systolic  murmur  at  the  apex 
of  the  heart. 

Operation,  May  25,  1903.— -lather.  Perineal  prostatectomy  by  the  usual 
technique.  Each  lateral  lobe  which  was  very  large  was  removed  in  three 
large  pieces,  this  was  necessary  because  the  blade  of  the  tractor  would 
not  remain  on  top  of  the  very  large  intravesical  lobes,  but  constantly 
slipped  beneath  them  so  that  when  one  large  lobule  was  removed  on  each 
side  it  was  necessary  to  again  place  the  tractor  upon  the  summit  of  the  re- 
maining intravesical  mass,  draw  it  down  and  enucleate  again.  In  this  way 
it  was  very  easy  to  remove  completely  a  very  large,  probably  pedunculated 
median  lobe  on  each  side.  The  urethra  and  ejaculatory  ducts  were  pre- 
served intact,  but  two  small  tears  were  made  in  the  vesical  mucosa,  none 
of  which  was  removed.  The  median  portion  of  the  prostate  was  not  dis- 
turbed. The  wound  was  closed  as  usual  with  double  catheter  drainage 
and  light  gauze  packs  for  the  cavities.  Patient  stood  the  operation  well. 
Infusion  and  continuous  irrigation.     Pulse  at  end  of  operation  80. 

Convalescence.— The  highest  temperature  was  on  the  fifth  day  after  the 
operation,  100.8°;  after  that  it  was  practically  normal  until  June  15,  when 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  167 

it  suddenly  arose  to  103.5°,  but  quickly  fell  to  normal.  The  continuous 
irrigation  was  kept  up  for  nine  days  "when  the  tubes  and  gauze  were  re- 
moved. There  was  incontinence  for  three  or  four  days,  but  after  that  con- 
trol was  established  and  he  could  retain  urine  for  five  hours.  The  urine 
did  not  pass  through  the  urethra  until  the  12th  day,  and  the  fistula  closed 
on  July  6,  the  42d  day.  On  June  6  a  retained  catheter  was  placed  in  the 
urethra  and  remained  for  three  days.  Following  the  patient  had  a  rise 
of  temperature  and  developed  epididymitis  which  continued  for  a  week, 
but  subsided  without  operation.  On  July  3  the  patient  had  another  sud- 
den rise  of  temperature  to  102°,  but  it  subsided  at  once  and  the  patient  left 
the  hospital  July  19  in  excellent  condition,  able  to  retain  urine  all  night 
and  voiding  only  three  or  four  times  in  the  day. 

January  llf,  1904- — Urination  is  normal  and  at  intervals  of  five  hours  in 
the  day  and  seven  hours  at  night,  no  incontinence.  Sexual  powers  are 
good.  After  ejaculation  the  semen  is  now  thrown  cut  of  the  meatus  (after 
Bottini  it  was  not).  Examination  of  the  semen  caught  in  a  condom  shows 
numerous  spermatozoa. 

February  1,  1905. — I  urinate  at  normal  intervals  and  am  entirely  cured. 
My  sexual  powers  are  normal. 

'November  13,  1905. — I  void  urine  naturally,  once  at  night,  three  or  four 
times  during  the  day,  a  half  a  pint  or  more  at  a  time.  I  have  no  fistula, 
no  pain.     Intercourse  is  entirely  satisfactory,  and  my  general  health  good. 

May  8,  1906. — 'Letter.  I  void  urine  naturally  three  or  four  times  during 
the  day,  and  twice  at  night,  a  half  pint  or  more  at  a  time.  I  have  no  pain. 
Sexual  intercourse  is  entirely  satisfactory.  My  general  health  is  excellent, 
and  I  consider  myself  cured. 

Case  12. — •Slight  hypertrophy  of  the  lateral  lobes.  Small  pedunculated 
median  lobe.  Post  operative  complication:  gauze  left  in  toound.  Pin  point 
fistula.    Cure.    FoUoiced  three  years.  , 

No.  408.     J.  R.,  age  70,  married,  admitted  May  26,  1903. 

Complaint. — '^'  Diflicuty  in  urination." 

No  history  of  gonorrhcEa. 

Present  illness  began  nine  years  ago  with  difficulty  of  urination.  At  the 
end  of  four  years  he  began  to  have  pain  during  urination  located  about  the 
middle  of  the  urethra.  In  February,  1902,  he  was  catheterized  and  a  quart 
of  residual  urine  obtained.  Since  then  he  has  used  a  catheter  off  and  on, 
although  he  has  never  had  a  complete  retention  of  urine. 

,Sf.  P. — He  voids  urine  five  or  six  times  during  the  night,  micturition  be- 
ing difficult  and  painful.  If  he  uses  the  catheter  he  is  able  to  go  four 
hours  without  urinating.  During  the  last  six  months  he  has  lost  very  little 
weight,  and  his  general  condition  is  good.  Sexual  powers  have  dimin- 
ished. Erections  only  occasionally  and  desire  for  intercourse  practically 
lost. 

Examination. — The  patient  is  a  fairly  strong  looking  man,  lips  of  good 
color.     Heart,  lungs  and  abdomen  negative. 


168  Hugh  H.  Young. 

Rectal  examination. — The  prostate  is  slightly  but  symmetrically  enlarged. 
It  is  firm  in  consistence,  but  is  not  markedly  indurated  and  has  no  nodules. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
480  cc.  residual  urine.  The  vesical  tonicity  is  good.  The  cystoscope  shows 
a  small  sessile  rounded  median  lobe  with  a  deep  sulcus  on  either  side.  A 
chronic  cystitis  is  present,  but  no  calculus.  Prostatic  secretion  contains 
pus  cells,  a  few  lecithin  and  granule  cells,  no  spermatozoa. 

Urinalysis. — ^Acid,  sp.  gr.  1018,  no  albumin  in  filtered  specimen,  no  sugar. 
Urea  G-19  per  liter.  Microscopically,  pus  cells,  bacilli  and  cocci,  no  casts. 
Total  urine  voided  in  24  hours  1750  cc. 

Operation,  May  29,  1903. — 'Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  right  lateral  lobe  was  not  at  all  enlarged,  was  quite 
fibrous  and  came  away  in  small  pieces.  The  left  lateral  lobe  came  away 
in  one  piece  measuring  4  x  2%  x  2  cm.  The  median  lobe  was  removed 
through  the  left  lateral  cavity  without  tearing  the  mucous  membrane  of 
the  urethra  or  bladder  and  leaving  the  ejaculatory  ducts  intact.  A  speci- 
men removed  is  shown  in  the  photograph  (see  Fig.  25a)  which  is  actual 
size.  The  wound  was  closed  as  usual  with  double  tube  drainage,  lateral 
cavities  being  packed  with  gauze. 

Commlescence. — Patient  reacted  well.  Continuous  irrigation  was  kept 
up  four  days.  The  packing  was  removed  during  the  first  week,  and  the 
tubes  on  the  tenth  day.  The  wound  broke  down  and  healed  slowly  by 
granulation.  After  removal  of  the  tubes  there  was  incontinence  of  urine 
which  persisted  until  the  patient  was  discharged.  Several  weeks  after 
the  operation  as  the  fistula  did  not  heal,  during  my  absence  in  Europe,  a 
catheter  was  placed  in  the  urethra  and  kept  there  for  eight  days.  Exami- 
nation at  the  end  of  that  time  showed  that  a  piece  of  the  packing  had  been 
left  in  the  wound,  and  after  its  removal  healing  proceeded  rapidly.  He 
was  discharged  on  August  6,  1903.  A  small  urinary  fistula  was  present, 
and  the  patient  was  able  to  retain  his  urine  for  several  hours.  His  gen- 
eral condition  was  excellent  and  he  was  free  from  pain. 

January  20,  1904. — Letter.  The  fistula  is  not  yet  closed,  but  I  void  urine 
in  a  large  stream  through  the  urethra  at  intervals  of  from  three  to  five 
hours.     I  have  no  pain,  have  erections  occasionally. 

April  22,  1904. — I  have  perfect  control  of  my  urine,  but  a  pin  point  fis- 
tula is  present.    I  can  retain  urine  for  five  hours. 

February  1,  1905. — I  void  naturally  at  intervals  of  from  three  to  six 
hours.    A  pin  point  fistula  persists,  but  I  have  no  pain  and  feel  well. 

November  30,  1905. — Letter.  I  void  urine  naturally  once  at  night  and 
about  three-  times  during  the  day.  Have  no  pain.  A  pin  point  fistula  per- 
sists, but  often  there  is  no  leakage  and  at  other  times  only  a  few  drops. 
I  feel  perfectly  comfortable,  my  general  health  is  excellent  and  I  have 
gained  40  pounds  in  weight.     I  have  erections  occasionally. 

May  7,  1905. — Letter.  I  void  urine  naturally,  once  at  night  and  three 
times  during  the  day,  large  amounts  at  a  time.  I  have  no  pain,  no  erec- 
tions.    My  general  health  is  excellent  and  I  consider  myself  cured. 


study  of  lJf-5  Cases  of  Perineal  Prostatectomy.  169 

Pathological  report. — The  specimen,  Path.  35,  consists  of  three  lobes 
weighing  Gr-17.  The  median  lobe  weighs  G~7,  and  measures  3x2x2  cm. 
The  left  lateral  lobe  is  about  the  same  size.  The  right  lobe  is  composed 
of  several  small  pieces  and  weighs  much  less  than  the  median.  On  sec- 
tion there  is  a  thin  capsule  surrounding  the  lobe,  and  the  typical  adenoma 
with  numerous  dilated  acini. 

Microsco-pic  study  shows  the  typical  spheroidal  arrangement  with  cap- 
sules containing  compressed  acini.  There  are  many  dilated  acini  with 
compressed  epithelium  of  a  columnar  type.  The  stroma  is  composed  of 
fibrous  tissue  and  smooth  muscle  loosely  bound  together  with  very  few 
areas  of  interstitial  inflammatory  deposits.  The  epithelium  is  well  pre- 
served, no  glandular  prostatitis  present.  Corpora  amylacea  fairly  num- 
erous. 

Case  13. — Yery  large  Jiypertrophy  of  median  and  lateral  lobes.  Old 
suprapubic  fistula.     Contracted  bladder.     Cure.    Followed  three  years. 

No.  518.     G.  G.  H.,  age  74,  married,  admitted  May  28,  1903. 

Complaint. — "  Enlarged  prostate.     Suprapubic  fistula." 

Gonorrhoea  in  1850,  light  attack,  no  complications.  ^ 

Present  illness  began  eight  years  ago  with  difficulty,  pain  and  frequency 
of  urination.  Progress  of  the  disease  was  gradual  until  June  11,  1902, 
when  retention  of  urine  became  complete  and  his  physician  was  unable 
to  pass  a  catheter  and  performed  suprapubic  cystotomy.  Since  then  he 
has  worn  a  supi-apubic  drainage  apparatus. 

S.  P. — The  patient  wears  a  suprapubic  apparatus,  no  urine  comes  through 
the  urethra,  there  is  considerable  leakage  around  the  tube,  he  suffers  pain 
and  is  uncomfortable. 

Sexual  powers. — He  has  erections  occasionally,  but  has  not  had  inter- 
course for  a  year.    His  general  health  is  good. 

Examination. — The  patient  is  a  robust  man,  lips  of  good  color,  arteries 
slightly  thickened,  pulse  82.  The  chest  and  abdomen  are  negative.  There 
is  a  large  suprapubic  fistula  in  which  the  patient  wears  a  tube  connected 
with  a  Bloodgood  bag.  Examination  of  the  bladder  through  the  fistula 
with  the  finger  shows  a  very  large  collar-shaped  hypertrophy  of  the  lateral 
and  median  lobes  which  stands  up  three  and  one-half  inches  above  the 
trigone  into  the  bladder,  the  upper  limits  reaching  to  within  1  cm.  of  the 
suprapubic  opening. 

Rectal. — The  prostate  is  greatly  hypertrophied,  the  right  lobe  being  the 
larger,  and  having  a  peculiar  lobule  projecting  from  its  lateral  border. 
The  prostate  is  smooth,  elastic,  the  notch  and  furrow  are  obliterated.  The 
seminal  vesicles  cannot  be  reached. 

Cystoscopic. — The  cystoscope  was  introduced  through  the  suprapubic 
opening.  The  intravesical  prostatic  enlargement  consisted  of  a  huge  mid- 
dle lobe  which  coalesced  without  intervening  sulci  with  two  large  lateral 
lobes,  between  which  there  was  a  deep  sulcus  in  front.  The  ureters  lay 
beneath  the  median  lobe  and  could  not  be  seen.  An  attempt  was  then 
made  to  cystoscope  the  bladder  through  the  urethra,  but  the  intravesical 


170 


Hugh  H.  Young. 


portion  was  so  great  that  the  instrument  could  not  be  passed  over  the  top 
of  it.  The  finger  in  the  suprapubic  wound  showed  that  the  end  of  the 
cystoscope  lay  in  the  space  in  front  of  the  median  lobe. 

Operation,  May  30,  1903. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes,  which  were  very  large,  were  removed  each 
in  three  large  lobules.  The  median  lobe  was  delivered  into  the  left  lat- 
eral cavity  and  enucleated  vrith  ease,  without  removing  any  of  the  mucous 


Fig.  41. — Large  lateral  and  median  lobes.     Exact  size. 


membrane  which  covered  it.  This  lobe  was  5  cm.  long,  3i^  cm.  wide,  and 
2^2  cm.  thick.  The  accompanying  photograph  shows  the  lobes  in  their 
relative  position  (Fig.  41).  The  urethra  and  ejaculatory  ducts  were  pre- 
served intact.  At  the  end  of  the  operation  a  finger  was  inserted  in  the 
suprapubic  fistula  and  showed  no  intravesical  prostatic  enlargement,  the 
mucous  membrane  covering  the  same  having  contracted  down  so  that  the 
vesical  neck  felt  almost  normal  in  smoothness.     The  perineal  wound  was 


study  of  lJ+5  Cases  of  'Perineal  Prostatectomy.  ITl 

closed  as  usual  ^\-itli  double  catheter  drain,  and  light  packs  for  the  lateral 
cavities.  Infusion  and  continuous  irrigation.  The  condition  of  the  pa- 
tient at  end  of  operation  was  good. 

Convalesceyice. — The  patient  reacted  well.  His  highest  temperature  was 
101°,  and  there  was  very  little  hemorrhage.  The  gauze  was  not  removed 
from  the  perineal  wound  until  four  weeks  after  the  operation  (the  op-' 
erator  was  away  on  vacation),  and  the  suprapubic  tube  in  six  weeks.  At 
that  time  the  perineal  wound  was  entirely  closed.  He  left  the  hospital 
on  the  55th  day,  his  condition  was  excellent.  Six  days  later  an  abscess 
developed  in  the  perineal  wound,  was  opened  by  his  physician  and  a  silk 
ligature  removed.  After  that  the  perineal  fistula  healed  promptly,  and 
urination  soon  improved. 

■January  23,  1904- — Urination  is  easy  but  painful,  and  occurs  at  intervals 
of  one  or  two  hours  night  and  day  Both  wounds  are  healed.  I  never  use 
a  catheter.  An  abscess  developed  in  the  perineum  shortly  after  my  return 
home,  but  after  the  removal  of  a  silk  stitch  the  fistula  healed.  I  suffer  all 
the  time  with  a  pain  in  the  neck  of  my  bladder  and  penis.  My  general 
health  is  good. 

May  20,  1904- — "  Urination  is  free  but  painful.  I  void  urine  at  intervals 
of  two  hours  during  the  day  and  three  or  four  at  night.  I  do  not  have 
erections."  The  patient  was  directed  to  have  bladder  examined  for  cal- 
culus. If  his  bladder  was  found  to  be  contracted,  to  use  hydraulic  dilata- 
tion. 

February  1,  1905. — I  urinate  about  every  three  hours  during  the  day 
and  four  or  five  hours  during  the  night,  one-half  pint  at  a  time.  Micturi- 
tion is  natural,  but  I  still  suffer  pain  in  the  penis  which  is  worse  during 
urination. 

Xovemter  30,  1905. — Last  August  I  went  to  Eureka  Springs  and  drank 
large  quantities  of  the  water  there.  My  bladder  became  three  times  as 
large  as  before  and  the  pain  disappeared.  I  now  feel  better  than  I  have 
for  six  years,  in  fact,  I  am  entirely  cured.  Can  retain  urine  five  hours 
during  the  day  and  nine  hours  at  night,  and  sometimes  void  a  pint  at  a 
time.    I  have  no  pain.    I  do  not  have  erections. 

May  8,  1906. — Letter.  The  wound  has  remained  closed.  I  am  cured.  [ 
void  urine  naturally  as  much  as  I  ever  did  and  often  pass  over  a  pint 
at  a  time.  I  have  no  pain.  I  do  not  have  erections  nor  sexual  intercourse. 
My  general  health  is  excellent. 

Pathological  report. — Specimen,  G.  U.  44,  consists  of  the  lateral  and 
median  portions  of  the  prostate  removed  In  six  pieces  and  weighs  about 
Gl~80.  The  left  lateral  lobe  has  been  removed  in  one  piece  measuring  4-X 
3.5  X  2.5  cm.,  is  globular  in  shape,  encapsulated  and  on  section  shows  large 
spheroids  with  a  moderate  amount  of  stroma  and  considerable  dilatation 
of  the  ducts.  The  right  lateral  lobe  has  been  removed  in  two  pieces  which 
measure  together  5  x  3.5  x  2.5  cm.,  and  is  similar  to  the  left,  except  that  the 
ducts  are  more  dilated.  The  median  portion  of  the  prostate  has  been  re- 
moved in  three  pieces,  forming  together  a  mass  5  cm.  long  and  6  cm.  wide 


172  Hugh  H.  Young. 

as  shOTrn  in  photograph.  It  is  smooth  and  on  section  shows  more  gland 
tissue  and  less  stroma  in  the  lateral  lobes.  No  mucous  membrane,  no 
ejaculatory  ducts,  no  calculus. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one,  with  the 
acini  arranged  in  lobules,  and  there  is  marked  cystic  dilatation.  The  ma- 
jority of  the  dilated  acini  are  lined  by  flattened  epithelium,  sometimes  one 
layer  and  sometimes  two  layers  thick.  In  areas  there  is  considerable  pros- 
tatitis present  with  endoglandular  proliferation  and  desquamation  and 
considerable  periacinous  formation  of  fibrous  tissue.  The  stroma  has  a 
considerable  excess  of  .fibrous  tissue  over  muscle,  and  there  is  a  fair  amount 
of  inflammatory  infiltration.  The  arteries  for  the  most  part  apparently 
show  no  thickening,  although  here  and  there  one  sees  a  vessel  whose  walls 
are  somewhat  thickened. 

Case  14. — Slight  enlargement  of  median  and  lateral  loies.  Residuum 
50  cc.  Capacity  150  cc.  Result:  Cure  of  obstruction.  Frequent  urination 
due  to  vesical  contracture.    Followed  two  years. 

No.  45S.  J.  M.,  age  57,  married.  Seen  at  request  of  Dr.  Casper  in  Ber- 
lin, Germany,  July  23,  1903. 

No  history  of  gonorrhcEa. 

Present  illness  began  seven  months  ago  with  sudden  complete  retention 
of  urine.  He  was  catheterized  and  one  and  one-half  liters  of  urine  with- 
drawn. Immediately  afterwards  he  had  a  convulsion  and  for  four  days 
was  comatose  and  was  expected  to  die.  He  finally  rallied  and  left  the 
hospital  February  27;  micturition  very  frequent,  generally  every  hour 
during  the  day  and  night.  He  consulted  Dr.  Casper  on  March  13,  1903, 
and  was  treated  by  intravesical  irrigations  through  a  catheter  with  con- 
siderable improvement.  He  returned,  however,  in  July,  complaining  of 
frequent  urination,  great  difficulty,  pain  and  spasm  in  the  bladder. 

S.  P. — The  patient  voids  urine  every  hour  with  a  great  deal  of  difficulty 
and  pain.     Sexual  powers:  No  note  made. 

Examination. — The  patient  is  a  sturdy-looking  man,  with  lips  of  good 
color.     Heart,  lungs  and  abdomen:   No  note  made. 

Rectal  examination. — The  prostate  is  slightly  hypertrophied,  smooth, 
hard,  but  not  of  stony  hardness,  no  nodules,  no  induration  in  the  region 
of  the  seminal  vesicles. 

Cystoscopic  examination. — A  catheter  passes  with  ease  and  finds  150  cc. 
residual  urine  (later  examination  residual  urine  50  cc,  bladder  capacity 
140  cc).  The  bladder  is  small  and  irritable.  The  cystoscope  shows  mod- 
erate intravesical  hypertrophy  of  both  lateral  lobes  and  a  small  media 
lobe  with  a  shallow  sulcus  on  each  side.  "With  finger  in  rectum  and  cysto- 
scope in  urethra  there  is  only  a  slight  increase  in  the  median  portion.  The 
urine  contains  considerable  pus. 

Operation,  July  2Jf,  1903. — ^Ether.  Perineal  prostatectomy  by  the  usual 
technique  with  the  kind  assistance  of  Dr.  Casper.  The  lateral  lobes  were 
only  slightly  hypertrophied  and  were  removed  each  in  one  piece.  The 
median  portion  of  the  prostate  was  small  and  removed  through  the  left 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  173 

lateral  cavity  without  tearing  the  urethra,  bladder  or  ejaculatory  ducts. 
Double  tube  drainage,  light  paclvs  for  the  cavities  and  the  usual  closure. 
The  patient  stood  the  operation  well. 

ConvaZescence.— 'The  temperature  did  not  rise  above  38°  C.  and  the  pulse 
ranged  between  70  and  75.  On  July  30  the  patient  began  to  have  pain  in 
the  wound  and  his  bowels  were  moved  for  the  first  time.  The  catheters 
were  removed  on  the  eighth  day. 

August  13,  1903. — The  patient  is  now  walking  about,  his  health  is  ex- 
cellent. Urine  passes  through  the  urethra.  Hydraulic  dilatation  of  the 
contracted  bladder  is  to  be  begun. 

July  13,  1904. — Letter  from  Dr.  Casper.  The  patient  is  in  good  health, 
urination  is  satisfactory  and  the  stream  large.  He  suffers  no  pain,  voids 
urine  three  or  four  times  during  the  night  and  about  every  two  hours 
during  the  day,  100  cc.  at  a  time.  He  has  not  used  a  catheter.  A  fistula 
continued  for  a  long  time,  then  closed,  but  recently  has  opened  again, 
but  only  a  few  drops  of  urine  escape  through  it.  The  patient  has  erections 
about  every  10  days,  but  has  not  attempted  intercourse. 

Case  15. — Considerable  enlargement  of  lateral  lobes.  Slight  median  bar. 
Catheter  life  tico  years.    Cure.    Followed  32  months. 

No.  477.     T.  C.  W.,  age  67,  married,  admitted  September  5,  1903. 

Complaint. — "  Retention  of  urine." 

No  note  as  to  gonorrhcea. 

Present  illness  began  three  years  ago  with  slight  difiiculty  at  the  begin- 
ning of  urination.  There  was  a  gradual  increase  in  the  trouble  and  two 
years  ago  complete  retention  of  urine  came  on.  Since  then  the  patient  has 
been  catheterizing  himself  about  three  times  every  day.  For  the  first 
few  months  of  catheter  life  the  patient  had  considerable  hematuria,  but 
since  then  the  urine  has  been  free  from  blood.  Erections  and  sexual 
powers  are  normal. 

Examination. — The  patient  is  a  well  nourished  man  with  lips  of  good 
color.  Heart,  lungs  and  abdomen  negative.  Genitalia  negative.  No  hernia 
present.     There  is  considerable  arteriosclerosis. 

Rectal  examination. — 'The  prostate  is  considerably  enlarged  in  both  lat- 
eral lobes,  the  left  of  which  is  the  larger  and  more  prominent.  The  upper 
end  of  the  prostate  cannot  be  passed. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
115  cc.  urine.  (Retention  of  urine  is  complete,  this  does  not  represent  the 
residual.)  The  bladder  capacity  is  340  cc.  The  tonicity  is  good.  The 
cystoscope  shows  considerable  intravesical  hypertrophy  of  both  lateral 
lobes  joined  by  considerable  median  bar.  The  bladder  is  trabeculated  and 
inflamed,  there  is  no  stone  present.  "With  the  finger  in  the  rectum  and 
cystoscope  in  the  urethra  the  beak  can  be  felt  and  the  thickness  of  the 
median  bar  is  moderately  increased. 

Urinalysis. — ^Pale,  1015,  acid,  no  sugar,  considerable  albumin,  pus  and 
epithelium.     Urea,  G-14  to  liter. 


174  Hugh  H.  Young. 

September  11,  1903. — Operation.  Ether.  Perineal  prostatectomy  by  the 
usual  technique  with  the  exception  that  the  prostatic  tractor  was  intro- 
duced through  a  urethrotomy  wound  in  the  bulbous  urethra  before  the 
inverted  V  incision  or  the  prostatic  enucleation  was  made.  DiflBculty  was 
encountered  in  getting  the  tractor  through  the  urethra  into  the  bladder, 
and  when  the  prostate  was  exposed  through  the  usual  technique  it  was 
found  that  the  tractor  drew  the  prostate,  not  into  the  wound,  as  usual,  but 
up  against  the  triangular  ligament.  The  exposure  was  not  so  good  and 
the  manipulation  of  the  tractor  was  more  difficult.  The  left  lateral  lobe 
was  quite  large  and  removed  in  one  piece  about  the  size  of  a  hen's  egg. 
The  right  lobe  was  smaller  and  came  away  in  two  pieces.  Examination 
seemed  to  show  no  remaining  median  bar  and  nothing  was  removed  from 
this  region.  A  small  tear  was  made  in  the  lateral  wall  of  the  urethra, 
but  no  mucous  membrane  was  removed,  and  the  ejaculatory  ducts  were 
preserved  intact.  The  lateral  cavities  were  packed  with  gauze,  a  soft  rub- 
ber catheter  was  introduced  into  the  bladder  through  the  urethrotomy 
wound  in  the  bulbous  urethra  and  both  cutaneous  wonds  were  partially 
closed  with  interrupted  sutures.  An  infusion  of  salt  solution  was  given 
on  return  to  the  ward  and  continous  irrigation  of  the  bladder  was  kept  up 
for  four  days. 

Convalescence. — The  patient  reacted  well,  and  suffered  slight  pain  in  the 
bladder  while  the  catheter  remained.  The  highest  temperature  was  101.2° 
on  the  day  after  the  operation.  The  gauze  and  tubes  were  all  removed  on 
the  eighth  day,  and  on  the  tenth  day  a  catheter  was  introduced  through 
the  penis  into  the  bladder.  The  catheter  was  finally  removed  during  the 
third  week,  but  the  fistula  did  not  heal  until  one  month  after  the  operation, 
and  a  nocturnal  incontinence  persisted  for  five  weeks.  During  the  fifth 
week  epididymitis  came  on,  but  subsided  in  four  days.  The  right  epididy- 
mitis was  alone  involved. 

October  17,  1903. — A  silver  catheter  passes  with  ease  and  finds  15  cc. 
residual  urine.  The  bladder  capacity  is  400  cc.  The  fistula  is  closed  and 
the  patient  has  complete  control.  The  patient  can  hold  his  urine  several 
hours.  The  urine  is  acid,  sp.  gr.  1015,  contains  considerable  albumin,  pus 
cells  and  bacteria. 

October  19,  1903. — The  patient  is  discharged.     Conditions  excellent. 

Letter.  Urination  is  easy  and  satisfactory,  and  I  can  hold  my  urine  four 
hours  in  the  day  and  only  get  up  twice  at  night.  The  fistula  closed  on 
the  21st  day.  I  have  not  used  a  catheter,  have  suffered  no  pain.  Erections 
have  returned,  and  I  have  had  intercourse  about  once  in  two  weeks. 

May  20,  1904- — I  can  hold  urine  for  five  hours  and  pass  about  200  cc.  at 
a  time.  Urination  is  normal,  I  have  no  pain,  and  my  sexual  powers  have 
returned. 

February  1,  1905. — 'I  void  naturally  and  consider  myself  cured,  only  hav- 
ing to  arise  once  at  night  to  urinate.  My  sexual  powers  are  the  same  as 
before  operation. 

November  30,  1905. — I  void  naturally  and  consider  myself  cured,  as  I 


study  of  IJfO  Cases  of  'Perineal  Prostatcctomij.  ITS 

only  have  to  urinate  once  during  the  niglit  and  three  or  four  times  during 
the  day.  Sexual  intercourse  is  the  same  as  before  operation.  My  general 
health  is  excellent. 

May  29,  1906. — Letter.  I  void  urine  naturally  four  or  five  times  during 
the  day  and  only  once  at  night,  about  half  a  pint  at  a  time.  I  have  no 
pain.  I  have  intercourse  the  same  as  before  operation,  but  the  penis  does 
not  get  so  hard.  My  general  health  is  good,  I  have  gained  in  weight,  the 
wound  has  remained  closed,  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  30,  consists  of  three  pieces, 
the  left  lateral  lobe  is  in  one  piece  and  measures  about  4x3x2  cm.  in 
size.  The  right  lobe  is  in  two  pieces  and  is  smaller  than  the  left.  Both 
lobes  present  the  usual  character  of  adenomatous  hypertrophy. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  glandular  one. 
The  acini  are  for  the  most  part  dilated,  and  in  certain  lobules  have  under- 
gone cystic  degeneration.  In  some  areas  the  acini  have  very  little  sup- 
porting stroma,  their  orifices  are  serrated,  and  there  is  at  times  much  in- 
traacinous  papillomatous  proliferation.  The  epithelial  cell  is  of  a  tall 
cylindrical  type,  the  lumen,  end  being  rather  granular  and  degenerated. 
At  times  there  is  only  one  layer  of  these  tall  cells,  but  often  in  many 
points  of  the  acini  the  epithelium  may  be  several  layers  thick,  the  deeper 
layers  being  rather  cuboidal  in  type.  Glandular  proliferation  within  many 
of  the  lobules  seems  very  active.  The  stroma  contains  a  fair  amount  of 
muscle,  but  the  connective  tissue  predominates.  There  are  some  few  areas 
of  prostatitis,  but  these  are  not  noted  in  areas  where  proliferation  is  ac- 
tive.   The  arteries  show  moderate  degree  of  arteriosclerosis. 

Case  16.^" — Huge  intravesical  hypertropliy  of  median  and  lateral  lo'bes  in 
man  aged  82.    Bemoval  of  240  grams  of  prostatic  tissue.     Cured. 

No.  541.    J.  A.  K.,  age  82,  single,  admitted  October  17,  1903. 

Complaint. — "  Prostatic  obstruction.     Suprapubic  fistula." 

No  history  of  gonorrhcea. 

Present  illness  began  24  years  ago  with  difficulty  of  urination,  accom- 
panied by  hematuria  aud  pyuria.  His  condition  improved  on  treatment  by 
hydrotherapy,  but  he  continued  to  have  trouble,  and  in  1887  had  complete 
retention  of  urine  for  the  first  time  and  was  catheterized  once.  After  that 
he  used  a  catheter  occasionally  on  advice  of  his  physician.  In  April,  1902, 
catheterization  was  impossible  and  a  suprapubic  cystotomj^  was  performed 
in  Washington.  Since  then  the  patient  has  been  wearing  a  rubber  catheter 
in  the  suprapubic  wound,  and  all  of  the  urine  has  come  through  this.  He 
is  unable  to  keep  dry,  is  uncomfortable  and  suffers  pain. 

Sexual  poicers. — ^No  note  made. 

Examination. — The  patient  is  a  fairly  strong  man  for  82  years.  His  lips 
are  of  good  color.     The  heart  and  lungs  are  negative. 

Ahdomen. — There  is  a  small  suprapubic  urinary  fistula  in  which  the  pa- 
tient is  wearing  a  soft  rubber  catheter. 

"  Case  No.  56  should  have  been  placed  here  as  Case  16.  To  change  the 
position  now  (in  proof)   seems  inadvisable. 


176  Hugh  H.  Young. 

Rectal. — The  prostate  is  greatly  hypertropliied,  presenting  a  broad  flat 
mass,  the  upper  limits  of  which  cannot  be  reached.  It  does  not  bulge 
greatly  into  the  rectum,  but  it  extends  far  upward  into  the  bladder,  and 
with  a  hand  above  the  symphysis  pubic  it  presents  as  a  large  intravesical 
mass  about  the  size  of  a  large  orange  which  is  easily  palpable,  especially 
on  bimanual  palpation  with  finger  in  rectum  and  hand  on  abdomen,  when 
the  immense  size  of  the  prostate  is  easily  made  out.  Rectally  its  surface 
is  smooth,  soft  and  not  tender.     The  seminal  vesicles  cannot  be  palpated. 

Cystoscopy. — tA  small  silver  catheter  is  passed  with  great  difficulty,  owing 
to  the  immense  size  of  the  intravesical  portion  of  the  prostate.  Urine  es- 
capes after  the  catheter  has  entered  for  a  distance  of  15  inches.  An  at- 
tempt was  made  to  'perform  cystoscopy  through  the  suprapubic  opening, 
but  although  it  was  easy  to  introduce  the  cystoscope  through  the  supra- 
pubic sinus,  the  beak  entered  at  once  into  the  cavity  in  front  of  the  me- 
dian portion  of  the  prostate  which  projects  far  up  into  the  bladder,  al- 
most completely  filling  its  cavity  and  rendering  it  almost  impossible  to 
introduce  the  cystoscope  into  the  bladder  behind  the  middle  lobe. 

Urinalysis. — Acid,  1020,  albumin  a  heavy  trace.  Urea  G-17  to  liter.  Pus 
cells  numerous. 

Operation,  Octo'ber  20,  1903. — Spinal  anesthesia  with  one-fifth  of  a  grain 
of  cocaine.  Perineal  prostatectomy.  The  prostate  was  easily  exposed 
through  an  inverted  V  incision.  The  urethra  was  opened  as  usual,  and  the 
tractor  inserted.  The  posterior  surface  of  the  prostate  was  so  immense 
that  it  could  not  be  drawn  down  between  the  ischio-pubic  rami,  and  the 
blades  of  the  tractor  were  so  short  that  they  would  not  take  hold  upon  the 
very  great  intravesical  lobes.  The  prostate  was  therefore  removed  in 
large  lobules  piecemeal.  The  operator  attempted  to  make  pressure  upon 
the  abdomen  and  thus  push  down  the  prostate,  but  the  patient  could  not 
stand  the  abdominal  pressure  which  gave  pain,  although  operation  upon 
the  prostate  was  painless.  No  attempt  was  made  to  preserve  the  urethra 
or  ejaculatory  ducts,  and  considerable  mucous  membrane  was  removed. 
The  right  lateral  lobe  and  median  lobe  were  completely  removed,  but  the 
deeper  intravesical  portions  of  the  left  lateral  lobe  had  not  been  completely 
removed  when  the  patient  became  so  weak  that  the  operator  decided  to 
stop  and  close  the  wound,  nevertheless  240  grams  of  prostatic  tissue  were 
removed.  The  immense  cavity  was  packed  with  gauze,  a  large  rubber  tube 
was  placed  in  the  bladder  through  the  perineal  wound  and  a  catheter  into 
the  suprapubic  sinus.  There  was  only  a  moderate  amount  of  hemorrhage. 
Pulse  at  the  beginning  of  the  operation  was  80,  and  at  the  end  68  but  weak. 
Submammary  infusion  was  given  during  the  operation.  The  anesthesia 
in  the  region  of  the  perineum  and  prostate  was  excellent,  but  suprapubic 
pressure  caused  pain.  The  patient  vomited  frequently  during  the  opera- 
tion and  was  distinctly  shocked  at  the  end. 

Convalescence. — After  injections  of  strychnia  and  water  the  patient  re- 
acted well  and  drank  large  amounts  of  water  and  ate  a  fairly  good  supper. 
For  one  week  he  had  a  temperature  between  101°  and  102°,  and  at  times 
was  slightly  irrational.    He  was  infused  on  the  fourth  day.    On  the  ninth 


study  of  lJj.5  Cases  of  ■Perineal  Prostatectomy.  177 

day  a  large  sloughing  lobule  of  prostatic  tissue  measuring  about  8x5x4 
cm.  in  size  was  found  in  the  perineal  wound  and  withdrawn.  Several 
days  later  a  second  lobule  was  removed  in  the  same  way.  These  were 
apparently  portions  of  the  left  lateral  lobe  which  had  been  loosened  by  the 
operator,  but  had  not  been  removed  on  account  of  the  condition  of  the 
patient.  The  perineal  fistula  being  still  open  five  weeks  after  the  opera- 
tion, a  retained  catheter  was  placed  in  the  bladder  through  the  urethra. 
This  catheter  was  left  in  place  for  several  days,  and  the  perineal  fistula 
promptly  healed  (38th  day).  After  that  the  patient  passed  urine  through 
the  penis  in  small  amounts,  but  the  suprapubic  sinus  which  was  lined 
with  epithelium,  although  reduced  to  a  pin  point  opening  refused  to  heal. 
He  left  the  hospital  eight  weeks  after  the  operation,  55th  day,  in  excellent 
condition. 

January  14,  IQOJf. — The  suprapubic  fistula  is  leaking  slightly,  at  night 
I  urinate  two  or  three  times  through  the  urethra;  if  I  let  too  long  a  time 
elapse  there  is  some  involuntary  discharge,  showing  a  lack  of  force  of 
contracture  at  the  neck  of  the  bladder. 

January  20,  1904- — A  pin  point  suprapubic  fistula  persists.  The  patient 
is  advised  to  have  this  excised. 

February  3,  1904- — Operation.  Cocaine.  Excision  of  muco-cutaneous  su- 
prapubic urinary  fistula.  The  fistulous  tract  was  very  fibrous,  and  was 
excised  in  one  piece.  As  the  dissection  proceeded,  it  was  possible  by  mak- 
ing traction  upon  the  fibrous  tube  to  draw  the  bladder  in  the  shape  of  a 
cone  up  into  the  skin  wound  where  a  circular  suture  of  catgut  was  placed 
in  the  bladder  muscle  around  the  base  of  the  fistulous  tract  which  was 
then  divided.  The  purse  string  suture  was  then  drawn  tight,  thus  effec- 
tually turning  in  and  closing  the  vesical  wound.  By  means  of  this  tech- 
nique it  was  possible  to  effectually  suture  the  bladder  through  a  very 
small  skin  incision.  The  muscle  and  subcutaneous  tissue  were  drawn  to- 
gether with  silver  sutures. 

Convalescence. — The  suprapubic  wound  healed  per  primam,  there  being 
no  leakage  at  any  time.  The  patient  left  the  hospital  in  12  days,  voiding 
urine  naturally  through  the  urethra. 

M.ay  23,  1905. —  Letter.  I  void  urine  in  a  good  stream  at  intervals  of 
from  three  to  five  hours  during  the  day  and  five  to  eight  hours  at  night. 
I  suffer  no  pain.  My  sphincter  is  a  little  weak  and  at  times  there  is  a 
slight  leakage.  The  patient  is  advised  to  wear  a  jock-strap,  thus  holding 
the  penis  against  the  abdomen  with  the  idea  of  doing  away  with  the  slight 
leakage. 

November  30,  1905. — The  wounds  have  remained  closed.  I  void  naturally 
once  at  night,  sometimes  not  at  all,  14  ounces  at  a  time.  During  the  day 
the  interval  is  about  four  hours,  but  there  is  occasionally  a  slight  leakage 
which  requires  the  use  of  a  cloth.  My  general  health  is  excellent.  I  am 
now  85  years  of  age. 

May  10,  1906. — My  condition  remains  the  same  as  stated  in  the  last  letter 
with  the  exception  of  a  slight  leakage.    My  general  health  is  good. 
Vol.  XIV.— 13. 


178  Hugh  E.  Young. 

Pathological  report. — The  specimen  consists  of  many  lobules  of  various 
sizes  with  smooth  encapsulated  surfaces  varying  from  1  to  5  cm.  in  diam- 
eter, and  weighs  200  grams.  The  sloughing  piece  removed  later  weighs 
about  40  grams.  A  number  of  lobules  are  covered  with  mucous  membrane, 
the  total  area  of  which  would  probably  amount  to  about  6  cm.  in  diameter. 
Section  of  the  lobules  show  typical  spheroids  of  the  usual  adenomatous 
hypertrophy. 

Microscopic  examination. — Two  sections  have  been  taken.  I.  Through 
a  lobule  covered  with  mucous  membrane,  a  portion  of  which  is 
vesical,  and  a  portion  urethral,  both  fairly  well  preserved.  In 
the  submucosa  there  are  considerable  cedema  and  round  celled 
infiltration  and  numerous  bundles  of  smooth  muscle.  The  lobule 
is  composed  largely  of  glandular  tissue  with  little  stroma.  The  ducts 
are  moderately  dilated,  and  there  is  considerable  intracystic  outgrowth 
of  epithelium  of  a  papillomatous  type.  Epithelium  is  a  tall  colum- 
nar variety  except  in  the  few  dilated  acini  where  it  is  moderately  flat. 
The  stroma  is  composed  of  fibrous  tissue  and  smooth  muscle  arranged 
more  or  less  circularly  around  the  acini  in  a  rather  loose  structure.  There 
are  no  masses  of  pure  fibroma  or  myoma — considerable  evidences  of  in- 
flammatory processes  are  present.  II.  Section  of  another  lobule  shows 
more  dilated  ducts,  and  here  and  there  considerable  inflltration  of  round 
and  polynuclear  cells  in  the  stroma.  The  lobule  is  surrounded  by  a  thick 
flbrous  capsule  in  which  flattened  acini  are  seen. 

Case  17. — Small  hypertrophy  of  median  and  lateral  loies.  500  cc.  re- 
siduum.    Cure.     Followed  31  months. 

No.  493.     J.  T.  McL.,  age  54,  married,  admitted  October  4,  1903. 

Complaint. — "  Frequency  and  diflBculty  of  urination." 

The  patient  had  gonorrhoea  about  23  years  ago. 

Present  illness  began  about  15  years  ago,  the  first  symptom  being  fre- 
quency of  urination  which  was  most  marked  during  the  night.  About  five 
years  later  he  noticed  that  the  stream  of  urine  was  small,  spiral  and  some- 
times divided.  In  the  next  few  years  both  difficulty  and  frequency  in- 
creased and  a  burning  during  urination  gradually  appeared.  About  one 
year  ago  the  patient  began  to  have  incontinence  both  night  and  day.  He 
has  suffered  considerable  pain  in  his  bladder,  but  has  never  passed  a  cal- 
culus. Four  years  ago,  on  the  advice  of  a  physician,  he  used  a  catheter  for 
two  months,  but  he  found  the  operation  disagreeable  and  has  only  used 
the  catheter  occasionally  since. 

S.  P. — The  patient  is  now  using  a  catheter  on  the  advice  of  his  physi- 
cian. If  he  does  not  do  this  he  has  incontinence  of  urine  and  a  large  re- 
siduum.    Sexual  powers  present. 

Examination. — The  patient  is  a  fairly  well  nourished  man  with  lips  of 
good  color.  Heart  and  lungs  negative.  Pulse  96  to  the  minute,  but  of 
poor  volume  and  tension.  Abdomen  negative.  Right  inguinal  hernia  is 
present.     Left  inguinal  ring  enlarged,  but  no  hernia  present. 


study  of  lJf-5  Cases  of  'Perineal  Prostatectomy.  179 

Rectal  examination. — ^The  prostate  is  very  little  enlarged  in  the  right 
lateral  lobe,  but  the  left  lateral  lobe  is  distinctly  enlarged  in  length  and 
breadth,  and  is  closely  adherent  to  the  structures  along  the  outer  border. 
The  contour  is  smooth,  consistence  firm,  but  not  markedly  indurated,  sem- 
inal vesicles  are  not  palpable.  The  fluid  obtained  by  prostatic  massage 
contains  spermatozoa  and  pus  cells,  very  few  normal  elements. 

Cystoscopic  examination. — Catheter  passes  with  ease  and  finds  about 
500  cc.  residual  urine.  The  vesical  tonicity  is  good.  Cystoscope  shows  in- 
travesical hypertrophy  of  slight  degree  of  both  lateral  lobes  with  a  sulcus 
between  the  two,  and  a  small  median  lobe  separated  from  each  of  the  lat- 
eral lobes  by  a  small  sulcus.  The  bladder  is  considerably  trabeculated, 
but  there  are  no  diverticula.  Considerable  cystitis.  With  finger  in  rec- 
tum and  cystoscope  in  urethra  the  median  portion  is  found  to  be  thick, 
but  the  beak  is  palpable  above  the  prostate. 

Preliminary  treatment. — 'The  patient  is  advised  to  catheterize  himself 
three  times  a  day,  to  take  urotropin  and  to  drink  water  in  abundance. 

Urinalysis. — Slightly  acid.  Sp.  gr.  1008.  Trace  of  albumin.  Micro- 
scopically, pus  cells. 

Operation,  October  26,  1903. — tEther.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  were  very  small  were  easily  enucleated, 
and  the  median  bar  was  removed  with  the  assistance  of  the  tractor  through 
the  left  lateral  cavity  without  disturbing  the  urethra  or  the  ejaculatory 
ducts.  After  the  removal  of  the  tractor  the  finger  was  inserted  into  the 
bladder  and  showed  a  small  pedunculated  median  lobe  which  was  too  small 
to  be  engaged  with  the  blade  of  the  tractor.  With  the  aid  of  the  finger  it 
was  easily  drawn  into  the  left  lateral  cavity  and  enucleated,  although  only 
8  mm.  in  diameter  and  weighing  only  G-2.  The  total  weight  of  the  pros- 
tate was  15  grams.  A  small  tear  was  made  in  the  mucous  membrane  cov- 
ering the  middle  lobe.  The  wound  was  closed  as  usual  with  double  tubes 
and  gauze  drainage.  There  was  very  little  hemorrhage.  Continuous  ir- 
rigation was  instituted  on  the  return  to  the  ward.  Pulse  at  the  end  of  op- 
eration 112,  condition  excellent. 

Convalescence. — The  patient  reacted  well.  The  temperature  did  not  rise 
above  100°,  and  after  the  third  day  was  normal.  The  gauze  was  removed 
on  the  second  day  and  tubes  on  the  fourth  day,  continuous  irrigation 
being  kept  up  for  four  days.  Urine  began  to  come  through  the  penis  about 
the  15th  day,  and  on  the  16th  day  a  note  was  made  that  he  was  able  to  re- 
tain his  urine  for  four  hours.  The  fistula  closed  on  the  21st  day,  and  he 
was  discharged  on  the  22d  day.  He  had  been  walking  about  the  wards 
since  the  12th  day.  The  catheter  passed  with  ease,  showed  no  evidence  of 
stricture,  and  withdrew  40  cc.  residual  urine.  Sounds  up  to  No.  26  F. 
showed  no  evidence  of  stricture. 

December  7,  1903. — Letter.  I  have  been  dohig  well,  but  one  week  ago 
epididymitis  set  in. 

May  22,  i9(?4-— 'Letter.  I  void  urine  about  every  three  hours.  I  have 
never  used  a  catheter  and  have  had  no  instrumentation  sir'^'^  the  operation. 


180  Hugh  H.  Young. 

I  void  about  one  pint  of  urine  each  time,  and  the  stream  is  large  and  free 
and  without  pain.  I  have  erections  twice  a  week  and  satisfactory  sexual 
intercourse.  The  sexual  desire  seems  to  be  slightly  diminished.  My  gen- 
eral health  is  excellent.  I  urinate  about  three  times  every  night,  a  pint 
at  each  time,  and  often  pass  three  and  one-half  pints  during  the  night. 

'November  30.  1905. — I  void  urine  naturally  a  pint  at  a  time  at  intervals 
of  three  hours.  I  have  erections  occasionally  and  sexual  intercourse,  but 
it  is  not  entirely  satisfactory.  I  have  no  -fistula  and  my  general  health  is 
fair. 

May  7,  1906. — ^Letter.  I  void  urine  naturally  five  or  six  times  during  the 
day  and  two  or  three  times  at  night,  about  one  pint  at  a  time.  I  suffer  no 
pain.  I  have  erections  and  sexual  intercourse.  My  general  health  is  much 
improved.    I  have  gained  20  pounds,  and  consider  myself  completely  cured. 

Pathological  report. — The  specimen,  G.  U.  48,  consists  of  three  pieces  of 
prostatic  tissue  weighing  in  all  15  gm.  The  consistence  is  rather  firm, 
and  an  occasional  spherical  lobule  is  seen.  The  ejaculatory  ducts  have  not 
been  removed.    No  calculus  present. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one  with  some  formation  of  lobules  which  are  rather  rich  in  acini.  The 
acini  within  these  lobular  areas  are  moderately  dilated,  the  lumen  is  ser- 
rated, and  they  are  lined  by  columnar  epithelium.  The  epithelium  in  some 
acini  is  one  or  two  layers  in  depth,  the  deeper  layer  being  rather  cuboid  in 
type.  In  other  acini  the  lining  consists  of  numerous  layers  of  epithelium. 
There  is  present  in  many  quite  extensive  areas  a  well  marked  glandular 
and  interstitial  prostatitis.  The  arteries  show  a  considerable  degree  of 
arteriosclerosis  in  many  areas.     Numerous  corpora  amylacea  are  noted. 

Case  18. — Considerable  lateral  enlargement.  Very  large  median  lobe. 
Complete  retention  of  urine.    Cure. 

No.  520.    W.  H.  H.  F.,  age  63,  single,  admitted  October  16,  190.3 

Complaint. — '"  Complete  retention  of  urine." 

The  patient  had  gonorrhoea  in  his  youth. 

Present  illness  began  about  two  years  ago  with  slight  difficulty  of  uri- 
nation. He  soon  began  to  have  considerable  dribbling  at  the  end  of  urina- 
tion. During  the  past  year  urination  has  become  much  more  frequent  and 
during  the  past  month  he  has  had  to  get  up  eight  or  ten  times  at  night 
to  urinate,  voiding  urine  in  small  amounts  and  with  considerable  pain. 
During  the  last  few  days  he  has  required  catheterization.  Erections  have 
been  absent  for  ten  years. 

Examination. — The  patient  is  a  sturdy-looking  man.  Mucous  membranes 
of  good  color.  Lungs  somewhat  emphs'sematous  but  clear.  Heart  slightly 
enlarged,  but  no  murmurs.     Abdomen  negative. 

Note  on  admission. — The  patient  has  complete  retention  of  urine.  A 
catheter  passes  with  difficulty  and  withdraws  very  bloody  urine.  The  pros- 
tate is  markedly  enlarged,  being  about  the  size  of  a  large  lemon  with  the 
long  diameter  transverse.     The  median  furrow  and  notch  are  obliterated. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  181 

The  contour  is  rounded,  and  the  prostate  is  smooth,  elastic  and  fairly 
soft. 

Cystoscopic  examination  is  impossible,  owing  to  hemorrhage. 

Preliminary  treatment. — ^A  catheter  was  fastened  in  the  urethra  and  con- 
tinuous irrigation  of  the  bladder  secured.  Urotropin  grains  20  to  30  daily 
by  mouth  was  administered.  On  October  22  the  patient  developed  a  left 
epididymitis. 

Octoter  26.  1903. — Operation.  Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  fairly  large  and  easily  enucleated. 
The  middle  lobe  measured  4x5x5  cm.  and  was  easily  delivered  into  the 
left  lateral  cavity  and  enucleated  without  tearing  the  bladder.  The  lateral 
cavities  were  packed  with  gauze,  double  catheter  drainage  was  supplied  to 
the  bladder  and  the  wound  was  closed  as  usual.  Patient  stood  operation 
well,  pulse  at  end  70.  Continuous  irrigation  and  infusion  on  return  to 
the  ward. 

Convalescence. — The  patient  reacted  well.  The  gauze  packing  was  re- 
moved on  the  sixth  day  and  the  tubes  on  the  eighth.  A  catheter  was  intro- 
duced into  the  urethra  on  the  thirteenth  day  and  removed  on  the  eight- 
eenth. He  was  up  in  a  wheel-chair  on  the  nineteenth  day,  and  was  dis- 
charged on  Dec.  7,  the  forty-third  day.  His  general  condition  was  excel- 
lent, but  there  was  still  a  small  fistula  in  the  perineum.  Highest  tempera- 
ture after  operation,  Nov.  8,  102°. 

January  29,  1904- — The  fistula  is  closed.  The  patient  says  that  he  voids 
urine  in  a  large  stream  and  about  250  cc.  at  a  time.  When  the  bladder  be- 
comes full  and  the  desire  to  urinate  comes  on,  there  is  apt  to  be  a  leakage 
of  a  few  drops  of  urine,  otherwise  there  is  no  incontinence.  A  catheter 
passes  with  ease  and  finds  40  cc.  of  urine.  He  has  not  been  instrumented 
and  there  is  no  evidence  of  stricture.    Bladder  capacity  395  cc. 

March  29,  1904- — A  silver  catheter  passes  with  ease.  Residual  urine  5 
cc.  is  present  and  bladder  capacitj^  450  cc.  The  cystoscope  shows  a  fold  of 
mucous  membrane  in  the  median  portion  of  the  prostate  and  a  small  lobu- 
lar projection  from  the  left  lateral  lobe  of  the  prostate.  There  is  no  ob- 
struction present.  The  ureters  are  easily  seen  and  they  are  functioning 
normally.  There  is  very  little  trabeculation  and  there  are  no  pouches  nor 
diverticula.  The  patient  has  been  treated  daily  by  intravesical  dilatation 
from  February  9  to  March  29.  At  the  beginning  the  bladder  only  held  220 
ce.  On  the  second  day  it  held  260  cc,  on  the  third  310  cc,  on  the  fifth 
345  cc,  and  on  the  sixth  410  cc  On  March  21,  1904,  470  cc.  were  intro- 
duced at  one  time.  Since  then  the  amount  has  been  slightly  less.  Under 
treatment  the  frequency  has  been  considerably  diminished. 

April  19,  1904- — The  patient  voids  urine  once  at  night  and  four  times 
during  the  day.  His  condition  is  excellent,  there  is  no  fistula,  no  incon- 
tinence. 

February  1,  1905. — I  void  urine  naturally  and  consider  myself  cured. 
Drink  large  amounts  of  water  and  void  urine  about  nine  times  in  twenty- 
four  hours. 


183  Hugh  H.  Young. 

November  30,  1905. — I  get  up  twice  at  night  to  urinate,  but  pass  250  cc. 
each  time.  I  have  no  difficulty  in  urination,  no  incontinence  and  can  hold 
urine  from  four  to  six  hours  during  the  day.  I  have  not  had  erections  for 
10  years.  Catheter  passes  with  ease  and  finds  20  cc.  of  residual  urine. 
There  is  no  stricture  or  fistula  present.    His  general  health  is  excellent. 

May  10,  1906. — The  patient  voids  urine  naturally  at  intervals  of  four 
or  five  hours  during  the  day  and  once  or  twice  at  night,  about  half  a  pint 
at  a  time.  He  has  no  pain,  no  incontinence,  no  difficulty  in  urination,  and 
considers  himself  cured.  Erections  which  were  absent  before  operation 
have  not  returned. 

Pathological  report. — Specimen  G.  U.  221.  The  specimen  consists  of  two 
small  lateral  lobes,  the  left  in  two  pieces,  one  1  cm.  in  diameter,  and  the 
other  3x2x1  cm.  The  right  lateral  lobe  measures  3x2x1  cm.,  and  on 
section  shows  several  distinct  spheroidal  lobules.  The  left  lobe  is  firmer, 
and  apparently  very  fibrous  in  character.  Several  areas  of  hemorrhage 
are  seen.  The  prostate  weighs  about  15  grams.  Three  sections  were  taken 
for  study. 

Microscopic  examination. — The  hypertrophy  tends  towards  the  fibro-mus- 
cular  type,  although  in  some  areas  the  bland  tissue  is  fairly  abundant. 
The  acini  in  these  areas  show  the  usual  typical  picture.  The  stroma  is 
largely  composed  of  fibrous  tissue,  there  being  present  practically  no 
muscle.  Some  areas  of  prostatitis.  The  arteries  &how  a  moderate  degree 
of  arteriosclerosis. 

Case  19. — \Large  intravesical  median  lobe.  Hematuria.  Little  difflculty. 
Cured.    Followed  25  months. 

No.  504.    R.  M.  D.,  age  54,  married,  admitted  November  28,  1903. 

Complaint. — "  Hematuria." 

Patient  has  never  had  gonorrhoea.  About  four  years  ago  patient  con- 
sulted Dr.  DaCosta  for  supposed  kidney  trouble.  The  urine  was  found 
negative  except  for  excessive  acidity.  He  was  advised  to  drink  water  in 
abundance  and  for  this  reason  urination  has  been  somewhat  frequent  for 
the  past  three  years.  He  dates  the  actual  onset  about  one  year  ago  when 
he  passed  a  few  clots  of  blood  with  the  urine  without  pain.  During  the 
past  year  he  has  had  five  attacks  of  painless  hematuria,  the  last  about  one 
week  ago.  He  has  never  passed  gravel  and  never  had  any  pain  in  the  re- 
gion of  either  kidney.  At  present  he  voids  urine  about  every  three  hours 
during  the  day  and  once  at  night.  He  has  never  used  a  catheter,  and  uri- 
nation is  not  very  difficult.  His  sexual  powers  are  slightly  diminished, 
erections  being  insufficient,  but  ejaculations  are  normal. 

Examination. — The  patient  is  pale,  but  otherwise  well  in  appearance. 
Heart,  faint  systolic  murmur  at  apex;  lungs  and  abdomen  are  negative. 
Rectal  examination  shows  a  considerably  enlarged  prostate  forming  a 
rounded  mass  about  the  size  of  a  medium-sized  orange,  smooth,  soft  and 
elastic.  The  seminal  vesicles  are  felt  and  there  is  no  induration  present. 
A  catheter  passes  with  ease  and  finds  220  cc.  residual  urine.    The  bladder 


study  of  lJf5  Cases  of  'Perineal  Prosiatectomy.  183 

capacity  is  450  cc.  The  cystoscope  shows  moderate  enlargement  of  the 
two  lateral  lobes,  and  a  sessile  rounded  median  lobe.  The  mucous  mem- 
brane covering  the  prostate  is  smooth  and  the  source  of  hemorrhage  can- 
not be  made  out.  The  bladder  is  moderately  trabeculated,  there  is  no  cys- 
titis present  and  no  calculus.  No  vesical  ulcer  or  tumor  is  to  be  seen. 
The  ureters  are  hidden  behind  the  median  portion  of  the  prostate. 

Urinalysis. — iClear,  neutral,  sp.  gr.  1022,  no  albumin,  no  sugar.  Micro- 
scopically negative. 

Note. — 'Although  the  patient  suffered  very  little  difficulty  and  frequency 
of  urination,  on  account  of  the  considerable  size  of  the  prostate  and  the 
attacks  of  intermittent  hematuria,  perineal  prostatectomy  was  advised. 

Operation,  December  1,  1903. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  left  lateral  lobe  was  the  largest,  measuring  5x3x2 
cm.  The  right  lateral  lobe  was  smaller  and  was  removed  in  two  pieces. 
The  median  lobe  was  removed  through  the  left  lateral  cavity  and  proved 
to  be  a  globular  mass  about  3  cm.  in  diameter.  The  deeper  portions  of  the 
lateral  lobes  were  markedly  adherent  and  a  small  area  of  mucous  mem- 
brane was  removed.  The  floor  of  the  urethra  and  ejaculatory  ducts  was 
preserved.  There  was  considerable  hemorrhage,  but  this  was  controlled 
by  a  pack  in  each  lateral  cavity.  Two  rubber  drainage  tubes  were  passed 
through  the  urethra  into  the  bladder  and  the  wound  closed  as  usual.  An 
infusion  of  1000  cc.  of  salt  solution  was  given  on  the  table,  and  his  condi- 
tion at  the  end  was  fair. 

Convalescence. — The  patient  reacted  well.  Continuous  irrigation  was 
not  used,  on  account  of  the  desire  to  avoid  vesical  infection.  The  drain- 
age tubes  were  placed  in  a  receptable  containing  a  solution  of  bichloride 
of  mercury.  The  gauze  was  started  on  the  second  day  and  finally  removed 
on  the  sixth.  The  rubber  drains  were  removed  on  the  eighth  day.  For 
two  days  the  urine  came  entirely  through  the  perineal  wound,  but  on  the 
tenth  day  it  suddenly  ceased  and  came  entirely  through  the  urethra,  and 
after  that  there  was  no  leakage  through  the  perineum  and  the  wound 
closed  rapidly.  As  soon  as  the  tubes  were  removed  the  patient  had  conti- 
nence. Temperature  between  100°  and  101°  for  two  weeks  after  the  opera- 
tion. He  was  walking  about  the  hospital  on  the  14th  day  and  was  dis- 
charged on  the  21st.  Examination  of  the  urine  showed  a  few  bacilli.  He 
had  been  taking  urotropin,  seven  and  one-half  grains  three  times  a  day, 
and  this  was  then  increased  to  five  times  a  day. 

December  29,  1903. — 'The  patient  is  drinking  large  amounts  of  water  and 
voids  a  great  deal  of  urine,  about  320  cc.  at  a  time  and  at  intervals  of 
about  two  hours.  There  is  no  incontinence,  but  urination  is  often  impera- 
tive. The  urine  is  cloudy,  and  contains  pus,  but  no  bacteria.  Silver  cath- 
eter passes  with  ease,  shows  no  evidence  of  stricture  and  finds  only  10  cc. 
residual  urine.  The  bladder  capacity  is  large  and  the  tonicity  is  excellent. 
Patient  says  he  had  one  erection  yesterday.  He  is  discharged  with  direc- 
tions to  continue  urotropin  and  helmitol  intermittently. 
Letter,  June  16,  1904- — I  void  urine  normally,  do  not  have  to  get  up  at 


184  Hugh  E.  Young. 

night,  and  have  no  pain.  The  amount  voided  at  each  time  is  about  one 
pint.  The  stream  is  large  and  micturition  normal.  Erections  have  re- 
turned, and  I  indulge  in  sexual  intercourse.    There  is  no  incontinence. 

December  2,  1905. — iThe  wound  has  remained  closed.  I  void  urine  natu- 
rally, four  or  five  times  during  the  day,  not  at  all  at  night,  and  as  much 
as  a  pint  at  a  time.  I  have  erections  and  satisfactory  intercourse,  but  there 
seems  to  be  less  power.    My  health  is  excellent  and  I  consider  myself  cured. 

Pathological  report. — Specimen  G.  U.  59.  The  prostate  has  been  removed 
in  four  masses,  and  weighs  60  grams.  The  middle  lobe  was  removed  in 
one  piece  and  weighs  10  grams.  The  left  lateral  lobe  was  removed  in 
one  piece  and  measures  5x3x2  cm.  in  size.  The  right  lateral  lobe  is  in 
two  pieces,  which  together  form  a  mass  about  the  size  of  the  left.  A  small 
area  of  mucous  membrane  has  been  removed  along  with  the  apex  of  the 
median  lobe  and  measures  about  1x1  cm.  in  size.  The  outer  surface  of 
the  lobules  and  the  cut  surface  shows  numerous  spheroids  with  interven- 
ing fibrous  stroma.  The  deeper  portion  of  the  left  lateral  lobe  is  firmer  in 
consistence,  and  on  section  shows  numerous  pin-head  areas  yellowish  in 
color,  and  suggests  malignancy  slightly. 

Microscopic  examination. — 'The  hypertrophy  is  a  glandular  one,  the  acini 
for  tlie  most  part  being  arranged  in  lobules.  Within  these  glandular  sphe- 
roids the  stroma  is  very  small  in  amount,  the  acini  are  dilated  and  there 
are  numerous  off -shoots  in  the  lumina  of  the  ducts,  oftentimes  papillomatous 
in  type.  The  interlobular  stroma  contains  acini  scattered  here  and  there, 
and  many  of  these  show  signs  of  activity.  A  few  small  areas  of  prostati- 
tis are  present.  The  stroma  contains  distinctly  more  connective  tissue  than 
muscle,  and  the  blood  vessels  seem  about  normal.  The  area  which  sug- 
gested malignancy  shows  the  acini  crowded  together,  and  filled  with  pro- 
liferating and  degenerating  cells,  but  no  evidence  of  malignancy. 

Case  20.. — Considerable  enlargement  of  lateral  lobes,  small  median.  Ne- 
phritis, suppression  of  urin^.    Cure. 

No.  517.    M.  V.  C,  age  78,  married,  admitted  November  11,  1903. 

Complaint. — "  Hematuria.     Frequent  and  i  ainful  urination." 

The  patient  denied  gonorrhoea.  Is  the  father  of  16  children,  the  young- 
est five  years  of  age. 

Present  illness  began  12  years  ago  when  he  passed  a  small  amount  of 
blood  without  pain.  After  that  he  had  slight  difficulty  in  urination  and 
occasional  hematuria.  During  the  next  few  years  hematuria  became  more 
frequent,  but  pain  was  always  absent.  Of  late  micturition  has  become  very 
frequent  and  difficult,  and  on  November  10,  1903,  complete  retention  of 
urine  came  on  for  the  first  time.  His  physician  was  unable  to  catheterize 
him  and  brought  him  to  the  Johns  Hopkins  Hospital  where  a  catheter  was 
passed  32  hours  after  the  onset  of  retention.  His  sexual  powers  are  good, 
and  his  desire  unchanged. 

Examination. — The  patient  is  well  nourished.  Mucous  membranes  of 
good  color.  Heart  and  lungs  negative.  Urine  is  slightly  cloudy.  Sp.  gr. 
1015.  Albumin  present.  Microscopically,  granular  casts  and  pus  cells 
present 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  185 

Rectal  examination  shows  the  prostate  moderately  hypertrophied,  soft, 
smooth,  tender  and  about  the  size  of  a  small  orange. 

Preliminary  treatment. — Soon  after  admission  a  coude  catheter  was  fast- 
ened in  the  urethra.  On  the  next  day  he  had  a  chill  and  fever  of  102°. 
During  the  next  three  days  almost  complete  suppression  of  urine  super- 
vened, but  after  infusions  and  rectal  injections  of  salt  solution  kidney  ac- 
tion was  again  established.  On  November  16  attempt  was  made  to  per- 
form cystoscopic  examination,  but  without  success,  owing  to  tendei-ness, 
pain  and  hemorrhage.  The  bladder  would  hold  only  40  cc.  fluid.  The 
urine  still  contains  albumin,  granular  and  epithelial  casts  and  pus  cells. 
Operation,  November  19,  1903. — ;Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Two  large  lateral  lobes  and  a  small  median  lobe  were 
easily  enucleated.  The  urethra  and  ejaculatory  ducts  were  preserved,  but 
a  small  tear  was  made  in  the  bladder  in  removing  the  median  lobe.  The 
wound  was  closed  as  usual  with  gauze  packing  for  the  lateral  cavities  and 
double  drainage  tubes  for  the  bladder.  A  submammary  infusion  of  salt 
solution  was  given  and  the  patient  stood  the  operation  well. 

Convalescence.-^Tla.Q  patient  reacted  well,  but  had  a  chill  soon  after  the 
operation.  His  highest  temperature  was  100°.  Saline  irrigation  of  the 
bladder  was  discontinued  on  the  third  day  and  the  gauze  completely  re- 
moved on  the  fourth.  The  tubes  were  removed  on  the  fifth  day,  and  the 
patient  was  up  in  a  wheel-chair  on  the  sixth. 

Noveniber  29,  1903. — For  the  last  few  days  the  patient  has  been  irra- 
tional and  temperature  has  been  subnormal,  but  his  pulse  has  been  good. 
He  was  infused  and  400  cc.  salt  solution  given  per  rectum  every  four  hours. 
December  8,  1903. — The  patient  is  improving  slowly.    Sinus  in  perineum 
persist. 

December  16,  1903. — Slight  pleurisy  is  present  on  the  left  side,  but  his 
temperature,  pulse  and  respiration  are  normal. 

December  19,  1903. — 'The  patient  has  improved  rapidly,  is  up  and  walking 
about. 

December  23,  1903.—<'His  general  condition   is  excellent.     The  sinus   is 
closing  slowly,  and  most  of  the  urine  comes  through  the  urethra.     The  pa- 
tient is  discharged   (34th  day).     Urine  is  acid.     Sp.  gr.  1016.     Albumin  is 
present,  and  numerous  pus  cells,  but  no  casts  are  seen. 
The  fistula  closed  on  about  the  45th  day. 

January  20,  190 4. —'Letter.  The  fistula  has  been  closed  for  some  time. 
I  have  little  if  any  pain.  I  have  no  inflammation  of  the  bladder  and  the 
urine  seems  normal.  I  void  urine  about  every  two  hours,  and  have  not 
used  the  catheter. 

May  22,  1904. — Letter.  I  urinate  once  during  the  night  and  about  every 
three  hours  during  the  day.  The  stream  is  large  and  free.  Erections  have 
returned  and  I  have  indulged  in  intercourse. 

February  1,  1905.— Letter.  Urination  is  normal,  about  six  times  in  24 
hours,  once  or  twice  at  night,  and  about  a  pint  at  a  time.  I  have  no  pain. 
I  have  ceased  to  have  erections,  and  this  is  what  I  regret  the  most. 


186  Hugh  H.  Young. 

November  30,  1905. — Letter.  The  perineal  wound  has  remained  closed. 
I  void  urine  naturally  about  a  pint  at  a  time  occasionally,  about  three  times 
during  the  night  and  eight  times  during  the  day.  I  suffer  no  pain.  Have 
no  erections.    My  general  health  is  good  and  I  consider  myself  cured. 

2ilay  9.  1906. — Letter.  I  void  urine  normally,  about  twice  during  the 
night  and  often  a  pint  at  a  time.  I  have  no  pain,  the  wound  has  remained 
closed,  and  I  feel  perfectly  cured.  My  general  health  is  excellent.  I  do 
not  have  erections. 

Pathological  report. — The  specimen  G.  U.  53,  consists  of  three  lobes 
weighing  in  aggregate  90  gm.  Two  lobes  are  about  equal  in  size  and  meas- 
ure each  4x5x5  cm.  in  size.  The  third  measures  1  x  1.5  x  2  cm.  The 
three  lobes  are  similar  in  character:  the  surface  is  nodular  and  lobulated, 
consistence  elastic,  homogeneous,  on  section  a  profuse  exudate  of  turbid 
milky  fluid  exudes  from  the  surface  which  is  composed  of  lobules  with  in- 
tervening fibrous  trabecule.     An  occasional  dilated  duct  is  seen. 

JJicroscopic  examination. — The  hypertrophy  is  a  lobulated  glandular  one 
with  areas  of  dilatation  and  marked  proliferation.  Some  cj'stic  degenera- 
tion is  present  with  flattening  of  the  lining  epithelium.  The  stroma  be- 
tween the  acini  except  in  the  interlobular  spaces  is  rather  loose,  and  con- 
tains fair  amounts  of  apparently  young  connective  tissue.  There  is  pres- 
ent also  considerable  muscle.  Numerous  areas  of  chronic  prostatitis  with 
interstitial  infiltration  are  seen. 

Case  21. — Sliglit  liypertropliy  of  median  and  lateral  lobes.  Catheterism. 
EmpTiysematoiiS  lungs.  Cardiac  murmurs.  Excellent  progress  for  13 
days.  Sudden  death  from  pulmonary  thrombosis  following  enema  on  IJfth 
day. 

No.  627.    W.  E.  :\I.,  age  73,  married,  admitted  November  20,  1903. 

Complaint. — "  Bladder  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  two  years  ago  with  frequency  and  difficulty  of  uri- 
nation which  gradually  increased,  and  six  months  before  admission  mic- 
turition became  very  difficult  and  painful.  Daily  catheterization  was  be- 
gun two  months  ago. 

S.  P. — Urination  is  very  frequent,  difficult  and  painful,  and  the  catheter 
is  used  frequently  by  the  patient  on  this  account.  The  bladder  is  con- 
tracted and  there  is  only  a  small  amount  of  residual  urine  present. 

Examination. — The  patient  is  a  fairly  well  nourished  man  with  lips  of 
good  color.     The  arcus  senilis  is  well  developed. 

Chest. — 'The  chest  is  well  formed,  the  lungs  are  clear  throughout  and 
somewhat  hyperresonant.  At  the  aortic  area  there  is  some  blurring  of 
the  heart  sounds  with  a  suspicion  of  a  diastolic  murmur.  The  pulse  is  70. 
The  abdomen  is  negative. 

Rectal. — The  prostate  is  only  slightly  hypertrophied,  smooth,  firmer  than 
normal,  not  tender.     The  seminal  vesicles  are  negative. 

Cystoscopic. — Coude  catheter  passes  with  ease  and  finds  residual  urine 


study  of  lJ/5  Cases  of  'Perineal  Prostatectomy.  187 

320  cc.  The  cystoscope  shows  a  slight  intravesical  hypertrophy  of  the  lat- 
eral lobe  and  a  small  rounded  median  bar.  The  ureters  are  easily  seen, 
and  there  is  only  moderate  cystitis  and  no  stone  present. 

Urinalysis. — Cloudy,  acid,  1020,  albumin  a  heavy  trace,  no  sugar,  urea 
15  gm.  to  the  liter,  25  gm.  daily.  Microscopically,  pus  in  considerable 
amount.    No  casts. 

Operation,  November  20,  i903.— 'Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  posterior  surface  of  the  prostate  showed  only  slight 
enlargement.  The  lateral  lobes  were  very  fibrous  and  removed  with  some 
difficulty.  The  median  portion  of  the  prostate  was  removed  through  one 
of  the  lateral  cavities,  and  was  small  in  amount,  a  small  tear  was  made 
in  the  urethra.  The  wound  was  closed  as  usual  with  double  tube  drainage 
and  light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation 
well,  the  pulse  at  the  end  being  80.  Infusion  and  continuous  irrigation  on 
return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  Pulse  did  not  rise  above  88 
on  the  night  of  the  operation  and  the  temperature  not  above  99.2°. 

November  21,  190.3. — The  patient  has  had  a  comfortable  day.  The  pulse 
has  varied  between  68  and  88,  and  the  temperature  between  98.6°  and 
100.2°.    He  has  been  comfortable  and  the  tubes  have  drained  well. 

November  22,  1903. — The  patient  has  had  a  good  day.  1580  cc.  urine  se- 
creted, pulse  good  72  to  84,  temperature  99°  and  100.4°. 

November  24,  1903. — The  patient  has  been  comfortable.  The  pulse  be- 
tween 80  and  104,  temperature  99°  to  100.4°.  The  patient  has  been  consti- 
pated, and  received  two  enemata  which  were  effectual. 

November  25,  1903. — The  patient  had  a  good  night,  slept  seven  hours, 
and  his  condition  is  excellent.  His  pulse  varies  between  82  and  92,  tem- 
perature between  99.2°  and  99.6°.  1800  cc.  urine  secreted.  Slightly  con- 
stipated, one  enema  given,  quite  effectual.  The  patient  is  on  soft  diet. 
Since  operation  the  pulse  has  had  a  peculiar  collapsing  quality. 

November  26,  1903. — The  gauze  was  removed  to-day  (sixth  day).  The 
condition  of  the  patient  is  good.  Temperature  99°  to  100°,  pulse  80  to  90. 
Urine  acid,  1023,  albumin  a  trace,  no  sugar,  total  amount  1800  cc.  Total 
urea  34  gm. 

November  27,  1903. — The  gauze  and  tubes  have  been  completely  removed, 
the  patient  is  in  good  condition.     Temperature  98.6°  to  100°. 

November  30,  1903. — The  patient  is  doing  well.  Pulse  70  to  80,  tempera- 
ture 90°  to  98°. 

December  1,  1903. — The  patient  has  had  a  slight  rise  of  temperature 
100.4°  associated  with  a  slight  epididymitis  on  the  right  side.  Condition 
otherwise  good.    Pulse  75. 

December  2,  1903. — The  epididymitis  is  subsiding,  and  causes  very  little 
inconvenience.  Pulse  80,  temperature  100.3°.  Patient  up  and  about  the 
ward.     Condition  excellent.     Wishes  to  go  home. 

December  3,  1903,  A.  M. — The  patient  is  in  excellent  condition.  Tempera- 
ture 98.7°,  pulse  80.  He  is  constipated  and  a  high  soap-suds  enema  is 
ordered. 


188  Hugli  H.  Young. 

p.  21. — This  morning  tlie  enema  was  very  effectual,  but  immediately  af- 
terwards the  patient  vomited  and  suddenly  collapsed.  "When  seen  by  one  of 
the  house  physicians  five  minutes  later  he  was  pulseless,  of  a  whitish  gray 
color,  but  the  respirations  were  fairly  good.  Strychnine,  atropine  and 
ether  were  administered  without  effect,  and  in  a  very  short  time  the  respira- 
tions stopped  and  the  patient  died. 

Autopsy. —  (Resume.)  There  was  a  firm  organized  clot  with  fresh  clot 
built  on  it  extending  from  the  right  auricle  down  the  inferior  vena  cava. 
There  was  also  a  thrombosis  of  the  pulmonary  artery.  Careful  examina- 
tion of  the  pelvic  structures  failed  to  throw  any  light  on  the  origin  of  the 
embolus.  There  was  some  old  clot  in  the  region  of  the  wound,  but  nothing 
unusual. 

Examination  of  the  interior  of  the  bladder  shows  no  intravesical  pros- 
tatic hypertrophy.  The  prostatic  orifice  is  about  5  mm.  in  diameter.  The 
median  portion  of  the  prostate  looks  as  if  it  had  not  been  disturbed, 
though  it  is  possible  that  a  pedunculated  intravesical  mass  has  been  re- 
moved. The  urethra  in  its  anterior  portion  communicates  along  the  lat- 
eral wall  with  the  cavity  left  in  the  removal  of  the  right  lateral  lobe. 
The  ejaculatory  ducts  are  apparently  preserved  intact.  The  verumon- 
tanum,  floor  of  the  urethra  and  left  lateral  wall  are  uninjured.  Small 
portions  of  the  lateral  lobes  in  their  deeper  portions  have  not  been  com- 
pletely removed.  There  is  no  evidence  of  hemorrhage  around  the  pros- 
tate or  the  rectum. 

Pathological  report. — The  specimen,  G.  U.  66,  consists  of  the  three  lobes 
of  the  prostate  removed  in  four  pieces,  and  weighs  about  20  gm.  The  me- 
dian lobe  measures  2.5x2x2  cm.,  is  oval  in  shape,  somewhat  irregular, 
and  on  section  shows  considerable  gland  tissue  and  a  small  amount  of 
stroma.  The  left  lateral  lobe  is  a  little  smaller  than  the  median,  is  com- 
posed of  several  large  spheroids  rather  loosely  bound  together.  The  right 
lateral  lobe  is  composed  of  two  pieces  measuring  3  x  2.5  x  2  cm.  No  mucous 
membrane,  no  ejaculatory  ducts,  no  calculi. 

Microscopic  examination. — The  hypertrophy  is  of  a  rather  glandular 
type,  the  acini  being  small,  closely  aggregated  with  quite  marked  com- 
plexity of  the  acini.  The  stroma  is  compact  and  contains  more  connective 
tissue  than  muscle.  The  blood  vessels  seem  normal.  Some  few  small 
areas  of  round  celled  interstitial  infiltration  are  present. 

Case  22. — Moderate  hypertrophy  of  lateral  and  median  loltes.  Catheter- 
ism.    Cure.    No  complications.    FoUoiced  tico  and  one-half  years. 

No.  488.    W.  T.  W.,  age  76,  married,  admitted  Nov.  20,  1903. 

Complaint. — "  Incomplete  retention  of  urine.     Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  four  years  ago  with  difiiculty  of  urination  which 
culminated  in  retention,  which  required  catheterization.  After  that  he  had 
to  be  catheterized  for  two  weeks.  In  January,  1901,  patient  had  a  chill  fol- 
lowed by  great  difficulty  in  urination,  and  after  that  he  had  to  be  catheter- 


study  of  lJf-5  Cases  of  'Perineal  Prostatectomy.  189 

ized  for  10  days  during  which  time  he  had  fever,  severe  pain  in  the  back 
and  urethra.  During  the  past  two  years  he  has  at  times  been  able  to  void 
without  the  catheter,  but  at  others  urination  was  so  difficult  or  frequent 
that  catheterization  from  two  to  four  times  a  day  was  necessary.  He  has 
had  several  attacks  of  fever,  chills  and  pain  in  the  back. 

8.  P. — The  patient  is  catheterized  three  times  daily,  about  three  hours 
after  catheterization  he  is  able  to  void  a  small  amount  of  urine.  The  total 
quantity  of  urine  voided  in  24  hours  is  usually  1300  cc,  of  which  800  is 
removed  by  the  catheter  and  about  500  cc.  voided.  He  suffers  no  pain, 
and  his  general  health  is  excellent. 

Sexual  powers. — He  has  erections,  but  has  not  had  intercourse  for  sev- 
eral years. 

Examination. — 'The  patient  is  a  well  nourished  man  with  lips  of  good 
color.    Chest  and  abdomen  are  negative. 

Rectal. — The  prostate  is  considerably  enlarged,  is  rounded,  smooth,  firm, 
but  elastic,  and  has  no  areas  of  induration  nor  nodules.  The  seminal 
vesicles  are  not  palpable. 

Urinalysis. — Slightly  cloudy,  acid,  sp.  gr.  1010,  albumin  a  marked  trace, 
no  sugar.  Urea,  15  gm.  in  24  hours.  Microscopically,  pus  cells,  hyaline 
casts  and  bacteria. 

Cystoscopic  examination. — A  rubber  catheter  with  a  stilet  passes  with 
ease,  and  finds  about  250  cc.  residual  urine.  A  cystoscopic  examination 
made  by  Dr.  Willy  Myer,  showed  a  moderately  enlarged  middle  lobe  on  a 
broad  base  with  very  little  enlargement  of  the  lateral  lobes.  There  was  no 
calculus  present.  The  bladder  was  trabeculated,  but  there  were  no  diver- 
ticula. Owing  to  the  pain  caused  by  this  examination  the  operator  did 
not  perform  cystoscopy. 

Operation,  November  22,  1903. — In  New  York.  Ether.  Perineal  prosta- 
tectomy by  the  usual  technique.  The  lateral  lobes  were  moderately  en- 
larged, very  adherent  and  were  removed  in  several  pieces.  The  median 
portion  of  the  prostate  was  only  moderately  enlarged,  and  was  removed 
in  pieces  through  one  of  the  lateral  cavities.  Examination  with  the  finger 
showed  no  remaining  prostatic  obstruction.  The  urethra  was  torn,  but 
no  mucous  membrane  was  removed  and  the  ejaculatory  ducts  were  pre- 
served. The  patient  was  infused  during  the  operation  and  continuous  irri- 
gation was  begun  at  the  end. 

Convalescence. — The  patient  was  very  little  shocked  and  convalesced 
rapidly.  He  was  up  walking  on  the  tenth  day  and  the  perineal  fistula 
closed  on  the  16th  day.  Patient  was  discharged  on  the  28th  day.  Six  weeks 
after  the  operation  a  catheter  was  passed  and  found  a  residual  urine  of 
30  cc.  and  a  bladder  capacity  of  120  cc.  His  physician  then  began  hydraulic 
dilatation  through  a  catheter  and  in  two  months  the  capacity  had  reached 
250  cc. 

March  23,  1904- — ^The  patient  is  in  excellent  health,  voids  urine  normally. 
Erections  have  returned.  Has  not  had  intercourse  for  years.  A  catheter 
passes  easily  and  finds  10  cc.  residual  urine.     Bladder  capacity  250  cc. 


190  Hugli  H.  Young. 

Urine  is  acid  and  contains  pus  cells  and  bacilli.  The  perineal  wound  is 
healed  and  rectal  examination  shows  an  absence  of  prostatic  enlargement. 
Urine  is  voided  at  intervals  of  from  two  to  five  hours. 

May  20,  190Jf. — Letter.  -I  can  retain  my  urine  five  hours  during  the  day 
and  the  same  time  at  night.  I  pass  250  cc.  at  a  time,  have  10  cc.  residual 
urine,  suifer  no  pain,  and  my  general  health  is  excellent. 

May  20,  1906. — Letter.  I  void  urine  naturally,  from  150  to  175  cc.  at  a 
time.  I  suffer  occasionally  a  very  slight  pain  in  the  perineal  wound,  but 
it  is  not  important.  The  catheter  is  occasionally  used  to  wash  out  the 
bladder  and  finds  15  cc.  residual  urine.  My  general  health  is  good,  I  have 
gained  in  weight  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  55,  consists  of  the  lateral  and 
median  portions  of  the  prostate  which  has  been  removed  in  eight  pieces, 
and  weighs  about  20  gm.  The  left  lobe  measures  3.5  x  2.5  x  2  cm.  and  has 
been  removed  in  one  piece.  It  is  composed  of  small  and  large  spheroids 
loosely  bound  together.  The  right  lobe  is  in  five  small  pieces,  mostly  sphe- 
roidal masses.  The  median  bar  and  lobe  is  in  two  pieces,  each  about  2x1 
X  1  cm.  in  size,  and  of  similar  appearance  to  the  rest  of  the  tissue.  On  sec- 
tion there  is  very  little  stroma,  considerable  dilatation  of  the  ducts  in 
places:  but  in  other  places  there  is  considerable  stroma,  but  no  dilated 
acini.  No  mucous  membrane  has  been  removed,  nor  ejaculatory  ducts.  No 
calculi  present. 

Microscopic  examination. — The  tissue  is  a  moderately  glandular  one,  the 
amount  of  gland  and  stroma  varying  in  different  areas,  but  as  a  whole 
the  gland  tissue  is  considerably  in  excess  of  the  stroma.  The  acini  are 
rather  small  with  occasional  areas  of  moderate  dilatation,  especially  in 
the  acini  of  the  spheroidal  lobules.  The  stroma  is  rather  dense  except  in 
the  more  glandular  lobules  where  there  is  considerable  spindle-celled  tis- 
sue present.  There  is  a  fair  amount  of  muscle  fibers  present  in  the  in- 
terstitial tissue. 

Case  23. — Patient  aged  81  years.  Moderate  enlargement  of  the  pros- 
tate v:hich  %i}as  considerably  indurated.  Pain  and  hematuria.  Calculus. 
2000  cc.  residuum.      Death  thirtieth  day.    Hypostatic  congestion  of  lungs. 

No.  623.    H.  C.  N.,  age  81,  married,  admitted  November  14,  1903. 

Complaint. — "  Bladder  trouble." 

No  historj'  of  gonorrhoea. 

Present  illness  began  about  three  years  ago  with  irritation  in  the  region 
of  the  bladder,  and  a  little  later  hematuria.  After  that  intermittent  hema- 
turia, but  no  pain,  no  passage  of  calculus,  no  obstruction  to  urination.  Six 
weeks  ago  he  felt  uncomfortable  in  his  lower  abdomen  and  examination 
showed  that  his  bladder  was  greatly  distended.  There  was  no  frequency 
of  micturition,  no  pain,  only  slight  difficulty  in  urination,  but  he  has  be- 
come weaker,  and  on  advice  of  a  physician  he  presented  himself  for  con- 
sultation. 

Examination. — ^The  patient  is  in  good  condition  for  his  age,  but  his  lips 
are  pale.  The  lungs  are  negative,  heart  sounds  are  clear,  but  intermittent. 
There  is  considerable  general  arteriosclerosis. 


study  of  Ho  Cases  of  'Perineal  Prostatectomy.  191 

Ahdomeji. — It  is  impossible  to  palpate  anything,  for  much  of  the  abdomen 
is  filled  with  a  distended  bladder  which  reaches  two  inches  above  the  um- 
bilicus.   Pressure  on  this  area  produces  pain.    The  genitalia  are  normal. 

Rectal. — The  prostate  is  considerably  enlarged,  very  hard  and  induration 
extends  upward  on  each  side  to  the  seminal  vesicles,  the  groove  is  oblit- 
erated and  the  surface  of  the  prostate  is  rough.  No  enlarged  glands  are 
to  be  felt.  A  small  coude  catheter  passes  with  some  diflaculty,  owing  to  a 
constriction  along  the  entire  prostatic  urethra.  Two  liters  of  pale  urine 
are  withdrawn.  The  bladder  is  still  not  emptied,  but  it  was  thought  in- 
advisable to  remove  all. 
Urinalysis. — Lost. 

Preliminary  treatment. — Catheterization  twice  daily.  Urotropin.  After 
four  days,  catheterization  had  become  more  difficult,  and  it  was  impossible 
to  introduce  a  catheter,  sounds  or  filiform  into  the  bladder,  owing  to  ob- 
struction at  apex  of  the  prostate.  Retention  of  urine  was  complete.  The 
bladder  was  distended  to  the  umbilicus,  and  the  patient  was  therefore 
advised  to  go  to  the  hospital  where  his  bladder  was  aspirated,  1800  cc.  of 
urine  being  withdrawn. 

Urinalysis  of  aspirated  urine. — Acid,  1015,  albumin  a  trace,  and  micro- 
scopically, a  few  hyaline  casts. 

The  bladder  was  aspirated  once  every  24  hours  for  five  days,  about  1200 
cc.  of  urine  being  withdrawn  each  time.  The  patient's  condition  re- 
mained good.  The  24  hours  total  of  urea  was  about  11%  gm.  and.  as 
catheterization  was  still  impossible,  it  was  thought  best  to  supply  peri- 
neal drainage,  and  at  the  same  time  to  remove  a  calculus  which  had  been 
felt  with  the  aspirating  needle. 

Operation,  Nov.  24,  1903. — Spinal  anesthesia.  Perineal  prostatectomy  by 
the  usual  technique.    Lithotomy. 

The  lateral  lobes  were  very  adherent  and  removed  with  difficulty,  scis- 
sors being  necessary.  There  was  no  median  lobe  present  and  with  the  fin- 
ger in  the  urethra  the  bar  did  not  seem  sufficiently  large  to  warrant  re- 
moval. Rough  oxalate  calculus  about  2  cm.  in  diameter  was  removed 
through  the  dilated  urethra.  Examination  showed  no  other  calculus.  The 
wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs  for 
the  lateral  cavities.  He  was  infused  on  the  table  and  stood  the  operation 
well,  but  while  being  returned  to  the  room  there  was  a  sinking  spell,  pulse 
became  irregular  and  weak.  He  was  given  strichnine  one-twentieth  of  a 
grain  and  soon  rallied. 

November  25. — Since  operation  yesterday  patient  has  been  comfortable. 
His  pulse  has  varied  between  88  and  100,  his  temperature  99.2°. 

'Novemher  28. — The  patient  is  doing  well.  There  is  profuse  drainage 
through  the  tube,  the  temperature  has  not  gone  above  100.5°,  pulse  be- 
tween 90  and  100. 

December  3. — ^The  patient  has  done  well.  Temperature  99°,  pulse  95. 
Sleeps  well.  Total  quantity  of  urine  1420  cc.  to-day.  Appetite  is  fairly 
good.    He  is  on  ordinary  diet.    The  tubes  and  gauze  are  removed  to-day. 


192  Hugh  H.  Young. 

Deceml)er  5. — The  tubes  had  to  be  replaced,  owing  to  the  fact  that  there 
was  no  drainage  through  the  perineal  wound,  and  the  bladder  became  dis- 
tended and  painful.  The  total  urine  to-day  was  1380  cc.  Highest  tempera- 
ture 99°,  pulse  88.  Patient  was  up  in  a  wheel-chair,  and  is  quite  com- 
fortable. 

December  11,  1903. — The  patient  has  complained  of  pain,  the  pulse  is 
weak  and  intermittent.  A  good  quantity  of  urine  has  been  secreted  daily, 
1200  to  1400  cc.  Sp.  gr.  is  1010.  total  urea  15  gm.,  there  is  only  a  trace  of 
albumin,  some  hyaline  casts  and  pus  cells.  The  tubes  were  removed  again 
to-day,  but  as  there  was  no  drainage  through  the  perineum  for  12  hours 
he  was  catheterized,  the  bladder  seems  to  have  no  tonicity. 

December  15. — The  patient  is  unable  to  void  and  is  catheterized  four 
times  daily.  He  is  very  weak,  and  his  pulse  is  intermittent.  Infusion 
1000  cc.  salt  solution  to-night.  The  patient  is  still  unable  to  void  and  is 
catheterized  four  times  a  day.  The  total  urine  is  about  1500  cc,  sp.  gr. 
1014,  and  there  is  considerable  pus  and  albumin.  The  patient  was  up  in 
a  wheel  chair  yesterday  for  three  hours  and  was  very  comfortable.  His 
temperature  has  been  normal,  and  his  pulse  stronger,  but  he  looks  weaker 
to-day. 

December  20. — Lungs  are  clear  but  emphysematous.  Heart  sounds  feeble 
with  a  faint  systolic  murmur.     The  pulse  is  very  intermittent. 

December  21. — There  is  an  abundant  secretion  of  urine,  1500  cc.  of  fair 
quality,  but  the  patient  is  gradually  sinking. 

December  23. — ^The  patient  is  much  weaker  and  near  the  end.  The  lungs 
are  full  of  fine  rales,  the  pulse  is  rapid  and  shallow,  120  to  140.  Still  se- 
creting an  abundance  of  urine,  1580  cc.  to-day. 

Urinalysis. — Acid,  1017,  albumin  considerable,  total  urea  9.4  gm.  Mi- 
croscopically, pus  cells,  hyaline  and  granular  casts.  Temperature  100.8°. 
The  patient's  mind  is  clear.  The  bladder  is  still  atonic  and  there  is  no  es- 
cape of  urine  except  through  the  catheter  which  enters  easily  and  meets 
no  obstruction. 

December  24. — The  patient  died  at  6  a.  m. 

Remark. — 'The  remarkable  feature  in  this  case  was  that  with  a  bladder 
which  was  distended  two  inches  above  the  umbilicus,  urination  was  very 
little  difficult  and  at  normal  intervals.  His  attention  was  attracted  by 
swelling  of  the  abdomen.  The  result  of  the  operation  was  not  perfect,  in 
that  normal  urination  was  never  established.  This  seems  to  have  been  due 
to  the  extreme  atony  of  the  bladder,  as  a  very  large  tube  could  be  inserted 
through  the  perineal  wound  with  ease.  Had  the  median  portion  of  the 
prostate  been  removed,  it  is  possible  that  drainage  would  have  been  estab- 
lished, but  the  patient  died  apparently  ijot  from  vesical  or  renal  complica- 
tions, but  from  old  age  and  cardiac  weakness.  Occurring  as  it  did  one 
month  after  the  operation  it  cannot  be  entirely  attributed  to  the  operation. 
Pathological  report. — Specimen,  G.  U.  65.  The  prostate  has  been  re- 
moved in  numerous  irregular  pieces.  The  weight  of  the  entire  prostate  is 
45  grams.  It  is  composed  of  numerous  small  and  large  spheroids  more 
or  less  firmly  bound  together.  No  mucous  membrane  or  ejaculatory  ducts 
have  been  removed. 


study  of  14-5  Cases  of  'Perineal  Prostatectomy.  193 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with 
formation  in  spheroids,  the  spheroids  being  separated  from  each  other  by 
bands  of  stroma  containing  flattened  acini.  The  culs-de-sac  show  the  usual 
complexity  due  to  the  intraacinous  growths.  The  stroma  is  rather  dense, 
and  is  composed  of  connective  tissue  and  muscle  in  about  equal  proportion, 
the  relative  amount  varying  in  different  areas.  There  is  present  quite  an 
extensive  prostatitis.     The  blood  vessels  are  about  normal. 

Case  24. — Slight  enlargement  of  median  and  lateral  lobes.  Castration 
and  Bottini  operations  previously.  Perineal  prostatectomy.  Recto-urethral 
fistula.  -Successful  closure  after  two  failures.  Death  at  end  of  one  year, 
pyonephrosis. 

No.  516.    O.  S.,  age  62,  single,  admitted  May  22,  1902. 

Complaint. — "  Bladder  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  11  years  ago  with  difficulty  in  urination, 
but  he  had  very  little  trouble  for  four  years,  when  urination  became  very 
difficult  and  frequent,  finally  complete  retention  of  urine  set  in  and  he  led 
a  catheter  life  for  nine  months.  After  that  he  catheterized  himself  only 
when  unable  to  void.  Micturition  is  usually  very  frequent,  often  six  or 
seven  times  at  night.  During  the  past  year  retention  has  again  been  com- 
plete, and  he  has  catheterized  himself  four  or  five  times  a  day.  In  October, 
1901,  castration  was  performed  in  another  city,  and  after  three  or  four 
days  he  began  to  void  naturally,  and  has  not  used  a  catheter  since. 

S.  P. — Urination  every  hour,  and  always  requiring  considerable  strain- 
ing, stream  being  small  and  slow.  The  patient  suffers  much  pain  in  the 
bladder,  but  has  never  passed  calculi  nor  blood.  He  is  habitually  consti- 
pated and  his  general  health  is  poor. 

Examination. — The  patient  is  a  thin,  nervous  looking  old  man  with  lips 
of  fairly  good  color.  Pulse  is  96,  of  good  volume  and  only  slight  arterio- 
sclerosis.    Heart,  lungs  and  abdomen  are  negative. 

Genitalia. — Both  testicles  are  absent.  The  scrotal  wounds  have  healed 
firmly. 

Rectal. — The  outlines  of  the  prostate  are  indistinct.  There  is  a  broad 
flat  mass  with  indefinite  borders,  extending  across  from  one  side  of  the 
pelvis  to  the  other,  and  upward  towards  the  region  of  the  seminal  vesicles. 
It  does  not  bulge  towards  the  rectum,  and  it  is  impossible  to  say  how  much 
of  it  is  prostate.     The  seminal  vesicles  cannot  be  felt. 

Cystoscopic. — Rubber  and  gum  catheters  meet  an  impassable  obstruction 
about  seven  and  one-half  inches  from  the  meatus.  A  silver  catheter  passes 
with  ease  and  finds  120  cc.  residual  urine  and  a  bladder  capacity  of  250  cc. 
The  cystoscope  shows  a  moderately  large  intravesical  hypertrophy  of  the 
lateral  lobes  and  median  portion  in  the  shape  of  a  collarette  with  a  single 
sulcus  between  the  lateral  lobes  in  front.  The  bladder  is  markedly  trabe- 
culated  with  numerous  small  pouches  and  the  bas  fond  behind  the  median 
bar  is  quite  deep.  No  calculi  are  seen.  With  finger  in  rectum  and  cysto- 
Vol.  XIV.— 14. 


194^  Hugh  H.  Young. 

scope  in  urethra  the  median  portion  of  the  prostate  is  definitely  increased 
and  the  entire  prostate  presents  as  a  hard  collar  2  cm.  thick  around  the 
shaft  of  the  instrument. 

Urinalysis. — Cloudy,  alkaline,  1010,  albumin  a  trace,  urea  13  gm.  to  the 
liter.    Microscopically,  pus  cells  and  bacilli. 

Operation,  June  2,  1902. — Cocaine  and  morphia.  Bottini  operation.  With 
blade  number  two  of  my  instrument,  three  cuts  were  made,  one  posterior 
and  two  lateral  each  2  cm.  long  with  the  instrument  at  a  white  heat.  The 
patient  stood  the  operation  well  and  there  was  very  little  hemorrhage. 
The  median  cut  was  made  with  the  guidance  of  a  finger  in  the  rectum. 

Convalescence. — iThe  patient  reacted  well,  and  urination  was  consider- 
ably improved.  The  residual  urine  rapidly  decreased,  but  the  patient  con- 
tinued to  suffer  pain.  He  was  treated  for  several  months  by  intravesical 
irrigations  and  urotropin  internally  with  very  little  benefit.  He  then  be- 
came very  melancholic,  avoided  the  association  of  other  people  and  often 
kept  himself  confined  to  bed. 

December  19,  1903. — The  patient  continues  to  be  very  melancholic.  He 
suffers  great  pain  in  the  bladder  and  urination  is  frequent  and  difficult. 

Examination. — A  catheter  finds  50  cc.  residual  urine  and  a  bladder  ca- 
pacity of  300  cc.  The  cystoscope  shows  a  small  rounded  median  lobe  with 
a  fairly  deep  cleft  on  each  side.  The  incisions  of  the  Bottini  cannot  be 
definitely  recognized,  but  it  seems  probable  that  the  clefts  represent  the 
two  lateral  incisions,  and  that  the  median  portion  has  increased  in  size 
since  the  Bottini  operation  was  performed.  The  bladder  is  only  slightly 
trabeculated  and  there  is  no  foreign  body  present. 

Remark,. — ^There  is  very  little  residual  urine,  and  the  patient  urinates 
better  than  before  the  Bottini  operation,  but  he  complains  considerably  of 
pain  and  seems  to  strain  during  urination.  It  is  therefore  thought  advis- 
able to  perform  prostatectomy. 

December  19,  1903. — Ether.  Perineal  prostatectomy  by  the  usual  tech- 
nique. Two  small  lateral  lobes  and  a  median  lobe  were  removed  with  con- 
siderable difficulty,  owing  to  the  fibrous  character  of  the  prostate  and 
marked  adhesions  to  capsule  and  urethra.  The  wound  was  closed  as  usual 
with  double  tube  drainage  for  the  bladder  and  light  packs  for  the  ^lateral 
cavities.  The  levator  muscles  were  not  drawn  together.  The  skin  wound 
alone  being  approximated  with  interrupted  sutures.  The  patient  stood  the 
operation  well,  pulse  at  the  end  being  80.  Continuous  irrigation  on  return 
to  the  ward. 

Convalescence. — ^When  the  gauze  was  removed  on  the  third  day  a  rectal 
fistula  was  discovered.  The  perineal  catheters  were  removed  on  the  ninth 
day  and  a  catheter  inserted  through  the  meatus  into  the  bladder.  It  re- 
mained in  place  for  about  a  week,  but  as  there  was  no  apparent  closure  of 
the  rectal  fistula  the  rectal  sphincter  was  divided,  thus  laying  bare  the 
fistula — (January  6,  1904.  The  penile  catheter  was  retained  until  Febru- 
ary 13. 

March  Jf,  1905. — The  urinary  fistula  shows  no  evidence  of  healing  and 
gas  escapes  through  the  urethra. 


study  of  lJj.5  Cases  of  ■Perineal  Prostatectomy.  195 

Operation,  March  If,  1904- — Ether.  Closure  of  urethral  fistula,  repair  of 
rectum.  The  urethra  was  opened  In  the  bulbous  region  and  the  prostatic 
tractor  introduced.  The  scar  tissue  was  then  dissected  from  the  perineal 
wound,  the  urethral  fistula  closed  with  interrupted  catgut,  the  edges  of 
the  rectum  freshened  and  sutured  with  a  continuous  suture  of  silver  wire 
reinforced  by  interrupted  catgut.  The  skin  wound  was  partially  closed. 
Light  iodoform  gauze  pack.  A  permanent  catheter  was  placed  in  the  blad- 
der through  the  bulbar  urethrotomy  wound.  The  patient  stood  the  opera- 
tion well.    Pulse  at  the  end  78. 

Convalescence. — The  patient  had  an  uncomfortable  convalescence.  Both 
wounds  broke  down.  Urine  escaped  into  the  rectum  and  gas  through  the 
penis.  He  continued  to  suffer  pain,  was  uncomfortable,  and  a  second  at- 
tempt to  close  fistulEe  was  made. 

Operation,  June  22,  1904. — Ether.  Closure  of  recto-urethral  fistula.  The 
operation  was  done  very  much  as  before,  except  that  the  urethral  fistula 
was  not  closed,  but  a  drainage  tube  was  brought  out  through  it.  The  rec- 
tal opening  was  closed  with  interrupted  sutures. 

Convalescence. — The  bowels  were  kept  tied  up  for  a  week,  and  the  pa- 
tient suffered  considerable  pain.  The  gauze  was  removed  on  the  fourth 
day  and  the  drainage  tube  on  the  sixth  day.  The  rectal  wound  again 
broke  down,  and  urine  again  flowed  into  the  rectum  and  out  the  perineal 
fistula  and  gas  into  the  urethra.     ^ 

Octoder  1,  1904- — The  rectal,  urethral  and  perineal  fistulse  persist.  The 
patient  suffers  a  great  deal  of  pain,  and  voids  urine  very  frequently.  He 
has  several  times  passed  calculi,  his  bladder  is  contracted  and  there  is  con- 
siderable cystitis. 

Operation,  October  6,  1904- — Ether.  Suprapubic  cystotomy  for  drainage. 
Removal  of  a  vesical  calculus.  Closure  of  rectal  and  urethral  fistula 
through  perineal  incision.  Fine  silk  was  used  in  the  closure  of  the  rectal 
fistula,  several  layers  of  interrupted  sutures  being  employed.  The  levator 
ani  muscles  were  drawn  together  over  the  wound  with  catgut.  The  urethral 
wound  was  closed  with  a  single  layer  of  fine  silk  sutures.  A  light  gauze 
packing  was  inserted  and  the  skin  was  partially  closed  with  interrupted 
sutures  of  catgut.  Suprapubic  drainage  was  supplied  through  a  large 
tube  around  which  the  bladder  was  sewed  with  catgut.  The  patient  was 
infused  on  the  table,  and  stood  the  operation  well,  his  pulse  at  the  end 
being  80. 

Convalescence. — The  patient  was  put  on  diet  of  water  and  albumin. 
Lead  and  opium  pills  were  given  to  prevent  bowel  movement.  Suprapubic 
tube  drained  well,  but  on  the  third  day  urine  leaked  through  the  perineal 
wound.  The  bowels  did  not  move  for  nine  days.  Calomel,  Epsom  salts, 
oil,  and  glycerine  enema  were  used.  Previous  to  this  the  patient  suffered 
considerably  from  abdominal  distention  and  pain. 

October  16,  1904- — The  patient  is  more  comfortable  and  his  condition  is 
fairly  good. 

October  22,  1904- — The  patient  has  been  very  excited  to-day,  thought  he 
was  in  a  cell  and  called  for  the  police. 


196  Hugli  H.  Young. 

'Kovem'ber  1,  1904- — The  patient  is  quiet  mentally,  and  the  suprapubic 
tube  is  draining  well.  The  rectal  wound  has  not  broken  down,  and  the 
perineal  urinary  fistula  is  small. 

Xovemier  21.  190If. — The  suprapubic  drain  has  been  removed.  A  small 
amount  of  urine  escapes  through  the  perineum,  but  the  rest  is  voided 
through  the  urethra.    The  patient  complains  of  pain  and  requires  morphine. 

Becemter  21,  190^. — The  patient  has  been  very  melancholic  during  his 
entire  stay  in  the  hospital.  He  has  had  delusions  of  persecution  and  at 
times  has  been  acutely  insane  for  a  short  time.  For  the  past  25  hours  he 
has  been  irrational  and  has  been  crying  almost  constantly.  His  temper- 
ature which  has  been  normal  since  October  9,  suddenly  arose  to-day  to 
103.3°,  and  his  pulse  to  130.    He  was  infused  with  1000  cc.  salt  solution. 

December  22,  1904- — The  patient  continues  irrational,  weak,  pulse  134 
to  160,  temperature  103.6^.  The  respiration  is  labored  and  he  has  diflBculty 
in  swallowing.  A  catheter  passes  through  the  urethra  into  the  bladder 
without  difficulty,  and  finds  no  residual  urine.  The  bladder  holds  only 
50  cc.  The  perineal  and  suprapubic  wounds  are  both  open,  but  the  rectal 
fistula  is  closed,  and  has  been  since  the  last  operation. 

December  23.  190Jf. — The  patient  died  to-day.  Autopsy  showed  double 
pyonephrosis,  pyoureter,  a  markedly  contracted  bladder,  considerable  cys- 
titis, small  suprapubic  and  perineal  fistulse.  The  rectal  wound  is  tightly 
healed,  and  there  is  no  prostatic  obstruction  present. 

Case  25. — Considerable  eyiJargement  of  lateral  lobes.  Small  median 
bar.  Very  frequent  and  difficult  urination.  Castration  previously.  Cure. 
Followed  twenty-nine  months. 

No.  528.     R.  M.  W.,  age  78,  married,  admitted  January  9,  1904. 

Complaint. — "  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  ten  years  ago  with  increased  frequency  of 
urination.  This  gradually  increased  and  urination  became  more  difficult, 
until,  in  1901  he  voided  as  often  as  30  times  during  the  night  and  about 
every  hour  during  the  day.  He  had  no  pain  and  passed  no  blood.  He 
then  began  to  use  a  catheter  and  after  that  occasionally  had  complete  re- 
tention of  urine.  In  April,  1901,  double  castration  was  performed  by  a 
physician  with  some  improvement,  but  the  catheter  was  necessary  as 
before. 

S.  P. — The  patient  urinates  16  or  18  times  during  the  night  and  about 
every  l^o  hours  during  the  day,  the  catheter  is  only  used  occasionally. 
His  general  health  is  good,  he  suffers  no  pain.  He  has  had  no  erections 
since  he  was  castrated. 

Examination. — The  patient  is  well  preserved  for  his  age,  with  lips  of 
good  color.  His  lungs  are  emphysematous.  Heart,  slight  systolic  murmur 
at  apex;    abdomen,  negative. 

Rectal. — The  prostate  is  considerably  enlarged,  symmetrical,  smooth,  soft 
and  elastic. 


study  of  lJi.5  Cases  of  'Perineal  Prostatectomy.  197 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1030,  trace  of  albumin,  no  sugar,  urea 
24  grams  to  the  liter.  Microscopically,  pus  cells  and  bacilli  in  consider- 
able number. 

Cystoscopic  examination. — Catheterization  is  difficult,  owing  to  an  ob- 
struction about  the  middle  of  the  prostatic  urethra.  A  very  small  silk 
coude  catheter  was  finally  passed.  The  urethral  length  is  eleven  inches. 
Residual  urine,  100  cc.  The  cystoscope  showed  a  fairly  large  median  bar, 
a  moderately  enlarged  right  lateral  lobe  and  a  larger  left  lateral  lobe,  with 
a  sulcus  between  the  two.  The  bladder  was  trabeculated  and  inflamed. 
There  was  no  foreign  body  present.  With  finger  in  rectum  and  cystoscope 
in  urethra  the  beak  could  not  be  reached  and  a  considerable  median  mass 
was  felt. 

Preliminary  treatment. — Regular  catheterization,  urotropin,  water  in 
abundance. 

Operation,  January  12,  1904- — Perineal  prostatectomy  by  the  usual  tech- 
nique, except  that  the  ejaculatory  bridge  was  cut  through  and  a  large 
median  bar  removed  in  this  way  from  beneath  the  urethra.  The  usual 
bilateral  capsular  incisions  were  made  and  two  very  large  lateral  lobes 
were  easily  enucleated  without  tearing  the  urethra  or  bladder.  After 
their  removal  it  was  decided  in  view  of  absence  of  testicles  to  cut  across 
the  ejaculatory  ducts  and  remove  the  median  bar,  which  was  thick  and 
fibrous,  thus  doing  away  with  the  necessity  of  extracting  it  through  one  or 
both  of  the  lateral  cavities.  The  bar  which  is  shown  in  the  accompanying 
photograph  (Fig.  33)  was  easily  enucleated  in  this  way,  but  a  small  tear 
was  made  in  the  floor  of  the  urethra.  The  operation  was  done  under 
spinal  anesthesia,  cocaine  gr.  %,  and  was  entirely  satisfactory.  A  sub- 
mammary infusion  of  1000  cc.  salt  solution  was  given  during  the  opera- 
tion, which  produced  no  shock.  The  wound  was  closed  as  usual  wittt 
double  tube  drainage  for  the  bladder,  and  light  packs  for  the  lateral  cavi- 
ties. The  entire  prostate  weighed  70  grams.  The  right  lobe  weighed  34, 
the  left  30,  and  the  median  6  grams. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to 
101.5°  on  the  day  after  the  operation,  but  after  that  was  very  little  above 
normal  for  two  weeks.  The  gauze  and  tubes  were  removed  on  the  fourth 
day. 

January  20,  1904- — The  patient  looks  weak,  is  nauseated,  but  the  wound 
looks  well. 

January  31,  1904- — Since  last  note  the  patient  has  had  very  little  appetite, 
an  evening  temperature  ranging  from  100°  to  101°  and  occasional  nausea. 
He  has  been  given  water  in  abundance,  liquid  diet,  and  has  been  up  in 
a  wheel  chair  as  much  as  possible.  Patient's  appetite  is  good  again  and 
his  temperature  is  normal. 

February  13,  1904- — The  patient  has  improved  steadily.  Is  walking 
about  the  hospital  and  is  comfortable.  Urine  came  through  the  penis 
on  the  27th  day  for  the  first  time. 

February  23,  1904. — The  patient   is   discharged,  forty-second   day.     The 


198  Hugh  H.  Young. 

fistula  closed  on  the  thirty-eight  day.  The  wound  is  healed,  and  the 
patient  is  voiding  urine  naturally.  His  general  condition  is  fairly  good. 
His  urine  is  clear,  contains  no  albumin,  and  microscopically,  only  a  few- 
casts. 

May  20,  190If. — Letter  from  physician.  "  A  stricture  has  formed  at  a 
place  where  the  urethra  was  incised  which  I  have  gradually  dilated  with 
steel  sounds  up  to  15  English,  previous  to  that  he  had  incontinence,  but 
now  this  has  ceased  and  his  urine  looks  good." 

November  4,  1904- — Letter.  "  I  have  to  void  every  one  to  three  hours 
during  the  day,  but  my  general  health  is  good."  He  is  advised  to  take 
bladder  irrigations  and  to  distend  the  bladder  as  much  as  possible  by 
hydraulic  pressure. 

February  1,  1905. — I  void  naturally  about  once  in  two  hours,  about  one- 
fourth  of  a  pint  at  a  time.     I  am  steadily  improving. 

November  30,  1905.— I  void  urine  about  once  in  two  hours,  but  during 
the  first  part  of  the  night  sleep  three  hours  without  urinating.  I  have 
some  vesical  irritability.  My  general  health  is  very  good.  My  wound  is 
closed,  and  I  feel  very  well  for  a  man  80  years  of  age. 

May  8,  1906. — Letter.  "  During  the  day  I  void  urine  naturally  about 
once  in  three  hours.  During  the  night  I  void  very  frequently,  probably 
from  10  to  20  times,  and  pass  from  a  teaspoonful  to  a  gill  at  a  time,  but 
during  the  day  perhaps  a  half  a  pint.  I  suffer  some  pain  when  urinating. 
I  suppose  that  my  trouble  is  catarrh  of  the  bladder  and  also  kidney 
trouble." 

Pathological  report. — The  specimen,  G.  U.  56,  consists  of  four  parts 
and  weighs  in  all  Gr-74.  The  right  lateral  lobe  measures  6x4x2.5  cm.,  is 
fairly  smooth,  lobulated,  elastic,  and  on  section  shows  gland  tissue  with 
a  moderate  amount  of  stroma  and  some  spheroids.  The  left  lobe  measures 
5x4x2.5  cm.,  is  smooth,  oval  and  on  section  presents  much  the  same 
appearance  as  the  right.  It  weighs  G-30.  The  median  bar  measures 
3x2x1.5  cm.,  weighs  G-9,  and  is  fairly  smooth  and  glandular.  No  mucous 
membrane  or  ejaculatory  ducts  are  attached  to  this.  The  fourth  piece  is 
a  portion  of  the  posterior  ca,psule  and  floor  of  the  urethra,  and  contains 
a  portion  of  the  ejaculatory  ducts. 

Microscopic  examination. — The  hypertrophy  in  all  three  lobes  consists  of 
very  much  more  stroma  than  gland  tissue.  The  acini  are  all  small,  sep- 
arated as  a  rule  by  very  broad  areas  of  stroma,  and  in  many  areas  only 
vestiges  of  gland  acini  persist.  Many  times  the  acini  seem  like  small  tu- 
bules of  solid  cells,  the  acini  being  so  compressed  that  no  lumen  is  visible. 
Many  of  the  larger  acini  are  filled  with  proliferating  epithelial  cells. 
The  stroma  is  almost  entirely  composed  of  fibrous  tissue,  and  only  occa- 
sionally are  seen  a  few  smooth  muscle  fibers.  Everywhere  throughout 
the  stroma  there  is  a  marked  round  celled  infiltration  and  occasional 
polynuclear  cells  are  seen.  About  most  of  the  acini  there  has  been  formed 
a  large  amount  of  new  inflammatory  tissue.  The  prostatitis  is  evidently 
one  which  is  very  extensive  and  of  long  standing.  The  arteries  show  a 
well  marked  degree  of  arteriosclerosis. 


study  of  IJf^o  Cases  of  Perineal  Prostatectomy.  199 

Case  26. — Considerable  JiypertropJiy  of  median  and  lateral  lobes  of  pros- 
tate. Urination  every  half  hour,  pain.  Perineal  prostatectomy.  Reeto- 
urethral  fistula.  Two  operations  to  close  fistula.  Final  cure.  Followed  28 
months. 

No.  584.     R.  K.,  age  61,  married,  admitted  December  30,  1903. 

Complaint. — "  Frequency  of  urination." 

No  history  of  gonorrhcea. 

Present  illness  began  about  five  or  six  years  ago,  with  frequency  of  uri- 
nation. Since  then  there  has  been  a  gradual  increase  in  difficulty  and  fre- 
quency. One  year  ago  he  began  the  use  of  a  catheter  on  the  advice  of  his 
physician.  Of  late  he  has  ceased  to  use  a  catheter  and  finds  that  he  has  to 
arise  very  frequently,  often  14  times  during  the  night  to  urinate.  He  has 
pain  when  the  bladder  becomes  full  which  persists  during  urination,  but 
does  not  radiate  to  the  end  of  the  penis.  There  is  considerable  difficulty  in 
starting  the  flow  and  much  straining  necessary  before  he  starts  to  urinate. 
He  has  never  had  complete  retention,  no  hematuria,  no  calculus. 

Sexual  powers. — Erections  are  present  occasionally,  but  the  patient  has 
not  attempted  intercourse  for  two  years. 

Examination. — The  patient  is  a  well  nourished  man  and  his  lips  and 
mucous  membranes  are  of  good  color.  The  lungs  and  heart  are  negative. 
Pulse  of  good  volume  and  tension,  but  quite  sclerotic,  88  to  the  minute. 
Hemoglobin,  70%.     The  abdomen  is  negative. 

Rectal  examination. — The  prostate  is  considerably  enlarged  in  both 
lateral  lobes,  firm,  but  elastic,  smooth,  no  nodules,  no  induration;  seminal 
vesicles  not  indurated. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
400  cc.  residual  urine.  The  cystoscope  shows  only  a  slight  intravesical 
enlargement  of  the  lateral  lobes  with  a  fair  sized  rounded  median  lobe, 
with  a  deeii  sulcus  on  each  side.  The  bladder  is  chronically  infiamed,  but 
there  is  no  stone  present. 

Urine.- — Acid,  1013;  cloudy;  no  sugar;  albumin,  a  trace;  microscopically, 
pus  and  bacilli. 

Preliminary  treatment. — The  patient  was  catheterized  three  or  four 
times  daily  for  18  days,  during  which  time  the  residual  urine  varied  from 
300  to  500  cc.  He  was  able  to  void  only  small  amounts,  and  the  total 
daily  quantity  was  from  1400  to  1900  cc.  The  urine  varied  in  specific 
gravity  from  1015  to  1022,  there  was  a  small  amount  of  albumin,  some  pus 
cells  and  a  few  granular  casts,  and  the  urine  was  acid.  Under  the 
treatment  above  described  the  patient  improved  considerably. 

Operation,  January  16,  190^. — Ether.  Perineal  prostatectomy  by  the 
usual  technique,  with  the  exception  that  no  examination  was  made  of 
the  rectum  at  the  end  of  the  operation.  The  operator  did  not  think,  how- 
ever, that  he  had  made  a  tear  into  the  rectum  and  no  note  was  made  of 
any  particular  difficulty  being  encountered  in  freeing  the  rectum  from 
the  prostate.  The  lateral  lobes,  which  were  moderately  hypertrophied, 
were  easily  enucleated  and  a  fairly  large  median  lobe  was  removed 
through  one  of  the  lateral  cavities  with  ease  by  means  of  the  tractor. 


200 


Hugh  H.  Young. 


With  the  finger  a  small  pedunculated  subcervical  median  lobe  was  re- 
moved (Fig.  42).  A  small  tear  was  made  in  the  urethra  in  so  doing,  but 
the  floor  of  the  urethra  and  ejaculatory  ducts  were  preserved  intact.  The 
wound  was  closed  as  usual,  with  exception  that  the  rectum  was  not 
examined  and  the  levator  ani  muscles  were  not  drawn  together  (up  to 
this  time  this  was  not  done  as  a  routine  procedure,  although  it  had  been 
done  in  the  very  first  operation). 

Convalescence. — The  patient  stood  the  operation  well,  pulse  at  the  end 
being  94.  Continuous  irrigation  was  kept  up  for  four  days,  when  the 
gauze  and  tubes  were  removed.  Two  days  later,  during  a  bowel  move- 
ment, feces  escaped  through  the  perineal  wound.  On  the  day  following 


Fig.  42. — Lateral  lobes,  moderate  median  bar,  small  pedunculated  sub- 
cervical  medium  lobe. 


the  operation  the  patient  complained  greatly  of  abdominal  pain  and  later 
pain  in  the  back.  He  was  given  calomel,  and  400  cc.  salt  solution,  with 
potassium  citrate  as  an  enema  to  be  retained,  this  was  repeated  three 
times  a  day  for  at  least  four  days,  a  large  rectal  tube  being  used  each 
time. 

Remark. — In  reviewing  the  case  there  seems  to  be  no  reason  for  this 
treatment  as  the  patient  was  not  nauseated,  had  no  fever,  temperature  be- 
ing normal,  and  his  condition  was  excellent,  with  the  exception  of  pain  in 
the  abdomen.  It  is  possible  that  the  traumatism  produced  by  the  frequent 
introduction  of  the  large  rectal  tube  caused  necrosis  of  the  rectal  wall 
adjacent  to  the  wound  and  led  to  the  fistula,  but  as  the  operator  did  not 
examine  the  rectum  after  the  operation  and  did  not  cover  it  by  approxi- 


study  of  lJf5  Cases  of  ■Perineal  Frostatectomy.  201 

mating  the  levator  muscles  tie  cannot  be  certain  what  caused  the  break- 
down. 

January  30. — Four  days  ago  the  rectal  sphincter  was  stretched  with  the 
patient  under  ether;  since  then  the  communication  between  the  rectum 
and  perineal  wound  has  been  very  free.  The  patient  feels  well  and  sits 
up  in  a  chair.     All  urine  escapes  through  the  perineum. 

February  4- — Most  of  the  urine  passes  through  the  penis;  some  feces 
still  discharge  through  the  perineal  wound.  The  perineal  wound  is 
packed  with  iodoform  gauze. 

February  11. — Little  improvement.  The  patient  passes  feces  through 
the  penis  when  the  bowels  move,  and  considerable  urine  comes  through 
the  rectum. 

February  20. — The  urine  starts  through  the  penis  but  very  soon  goes  into 
the  rectum.  Gas  and  feces  escape  through  the  penis.  The  patient  voids 
urine  at  intervals,  has  good  control  and  has  no  pain  in  his  bladder. 

Operation,  February  20,  1904- — Ether.  Closure  of  urethro-rectal  fistula. 
A  probe  was  introduced  through  the  sinus  and  perineum  and  the  sinus 
was  then  excised  through  an  inverted  V-incision  in  a  scar  of  the  previous 
operation.  After  both  fistulge  had  been  thoroughly  exposed  an  incision 
was  made  in  the  bulbous  urethra  and  a  catheter  inserted  through  it  into 
the  bladder.  The  rectum  and  urethral  openings  were  then  closed  with 
fine  sutures  of  catgut,  and  these  were  reinforced  with  heavier  catgut 
sutures.  The  urethral  catheter  was  sewed  to  the  edge  of  the  bulbous 
urethrotomy  wound  for  permanent  drainage. 

Convalescence. — The  patient  suffered  considerably  from  pain.  The  cath- 
eter did  not  drain  well,  and  caused  so  much  pain  that  it  was  removed  on 
February  24. 

February  25. — Urine  escapes  through  the  perineum  and  rectum.  The 
patient  has  suffered  greatly  from  diarrhoea  since  the  operation  and  this 
has  caused  the  wou-nd  to  break  down. 

March  2. — Fecal  matter  comes  through  the  perineal  wound  in  consider- 
able amount,  and  urine  entirely  through  the  perineum  and  rectum. 

March  12. — The  patient  is  much  improved.  Nearly  all  the  feces  pass 
through  the  anus.  Urine  comes  mostly  through  the  penis.  Sinuses  show 
evidence  of  closing. 

March  19. — Patient  is  discharged  to-day  (four  weeks  after  second  oper- 
ation). He  feels  well,  voids  urine  every  four  or  five  hours.  At  night  does 
not  void  from  12  to  6  a.  m.  Most  of  the  urine  comes  through  the  urethra 
in  a  large  free  stream  and  without  pain.  Ten  days  ago  the  amount  of  fecal 
matter  coming  through  the  perineum  began  to  diminish  and  for  the  past 
few  days  there  has  been  no  escape  of  fecal  matter.  There  has  been  no  fecal 
matter  nor  gas  come  through  the  urethra  since  the  second  operation. 

April  16. — The  patient  is  very  comfortable.  Only  a  few  drops  of  urine 
escape  through  the  perineum  and  very  little  gas  and  no  fecal  matter. 
There  is  no  connection  between  the  rectum  and  urethra.  Voids  urine  at 
intervals  of  six  hours  with  perfect  comfort. 


202  Hugh  H.  Young. 

August  2,  1904. — The  patient  feels  well,  voids  urine  at  intervals  of  five 
or  six  hours.    Both  rectal  and  urethral  fistula  are  closed. 

November  30,  1905. — I  void  urine  naturally,  one  pint  at  a  time,  about 
every  four  hours.  A  few  drops  of  urine  still  escape  through  the  perineal 
fistula.  Erections  are  present.  My  health  is  good  and  I  have  gained  50 
pounds.     I  have  no  pain  and  I  consider  myself  cured. 

February  16,  1906. — Letter.  I  void  urine  once  during  the  night,  oc- 
casionally twice,  and  generally  six  times  in  2  hours.  The  fistula  is  improv- 
ing and  sometimes  for  nearly  a  week  there  is  no  leakage.  Occasionally 
a  slight  amount  of  gas  passes  through  the  penis,  but  never  any  fecal 
matter,  and  no  fecal  matter  ever  passes  through  the  perineum.  There 
is  no  tenderness  about  the  bladder,  but  at  times  a  little  pain  when 
urinating.    My  general  health  is  very  good. 

May  17,  1906. — Letter.  I  void  urine  naturally  three  or  four  times  during 
the  day  and  generally  twice  at  night,  about  a  pint  at  a  time.  At  times 
I  suffer  slight  pain  during  urination,  but  only  occasionally.  I  have 
erections,  but  have  not  attempted  intercourse.  The  perineal  fistula  is  not  en- 
tirely closed,  occasionally  eight  or  ten  drops  of  urine  escape  through  it. 
My  general  health  is  good,  I  have  gained  in  weight,  and  I  am  entirely 
cured  of  my  prostatic  trouble. 

Pathological  report. — Specimen  G.  U.  58.  The  prostate  has  been  re- 
moved in  four  pieces  and  weighs  about  35  grams.  It  consists  of  a  left  lobe 
4.5x3x2  cm.  in  size,  the  right  lobe  4.5  x  2.5  x  2  cm.,  a  median  bar  globular 
in  shape  and  about  2  cm.  in  diameter,  and  a  small  intravesical  lobe  about 
8  mm.  in  diameter.  The  specimens  are  covered  by  smooth  mucous  mem- 
branes, are  elastic  and  present  the  usual  appearance  of  benign  glandular 
hypertrophy. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with  the 
formation  of  spheroidal  lobules.  The  acini  show  rather  marked  cystic 
dilatation  in  areas.  The  interlobular  stroma  contains  •  some  acini  which 
are  fiattened  and  elongated.  The  stroma  is  comprised  for  the  most  part 
of  connective  tissue,  although  there  is  present  a  considerable  amount  of 
muscle.  A  rather  extensive  chronic  prostatitis  is  present  and  in  areas  this 
has  led  to  the  formation  of  considerable  periacinous  sclerosis  with  conse- 
quent compression  and  partial  atrophy  of  the  acini.  The  picture  in  these 
areas  would  suggest  a  primary  glandular  proliferation  with  subsequent 
atrophy  of  the  gland  elements  as  a  result  of  inflammation.  The  blood 
vessels  show  moderate  degree  of  arteriosclerosis  in  these  areas. 

Case  27, — Moderate  hypertrophy  of  mediati  and  lateral  lobes.  Consider- 
able pain  and  hematuria.    Cure. 

No.  606.    J.  T.  N.,  age  58,  married,  admitted  January  21,  1904. 

Complaint. — "  Enlarged  prostate — cystitis." 

The  patient  has  never  had  gonorrhoea. 

Present  illness  began  in  May,  1903,  with  a  slight  difficulty  of  urination. 
At  the  end  of  a  month  blood  appeared  at  the  end  of  each  urination,  which 


study  of  UfO  Cases  of  'Perineal  Prostatectomy.  203 

was  very  difficult.  His  physician  then  passed  a  catheter  and  drew  away 
about  two  quarts  of  urine.  He  was  catheterized  once  daily  for  a  month, 
and  after  that  urination  was  fairly  satisfactory  until  September,  1903, 
when  dysuria  and  hematuria  returned.  His  physician  then  passed  sounds 
twice  a  week  for  a  month,  and  during  the  next  three  months  the  patient 
got  along  fairly  well  by  using  the  catheter  at  bed  time.  In  January,  1904, 
urination  became  much  more  difficult  and  a  severe  hemorrhage  occurred. 

S.  P. — The  patient  is  voiding  urine  every  hour  with  considerable  diffi- 
culty. Hematuria  is  present,  sometimes  large  clots  are  passed.  He  has  no 
pain  except  in  his  bladder,  has  not  lost  weight.  His  sexual  powers  are 
normal. 

Examination. — The  patient  is  well  nourished.  Heart,  lungs  and  abdomen 
are  negative.  There  is  no  arteriosclerosis  and  his  pulse  is  good.  Geni- 
talia are  negative. 

Rectal  examination. — iThe  prostate  is  considerably  enlarged,  smooth, 
fairly  firm  but  homogenous  and  not  nodular.  The  seminal  vesicles  are  not 
palpable. 

Cystoscopic  examination. — A  catheter  enters  with  ease,  but  withdraws 
only  32  cc.  residual  urine.  (At  a  previous  examination  complete  retention 
of  urine  was  present  and  the  bladder  reached  the  umbilicus.)  The  cysto- 
scope  shows  two  large  intravesical  lateral  lobes  with  a  very  small  median 
bar  connecting  them.  The  bladder  is  moderately  trabeculated  and  inflamed. 
The  urine  is  cloudy,  acid,  and  contains  pus  cells  in  abundance. 

Operation,  January  21,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  moderately  enlarged,  soft  and 
easily  enucleated.  The  median  portion  of  the  prostate  was  delivered  by  the 
tractor  into  one  of  the  lateral  cavities  and  enucleated,  being  about  3  cm.  in 
diameter.  The  urethra  and  ejaculatory  ducts  were  preserved,  but  a  small 
tear  was  made  in  removing  the  median  lobe.  The  perineal  wound  was 
lightly  packed  with  gauze,  double  catheter  drainage  was  introduced  into 
the  bladder  through  the  perineal  wound  which  was  closed  as  usual.  The 
patient  was  infused  on  the  table  and  continuous  irrigation  was  provided 
on  return  to  the  ward.    The  patient  stood  the  operation  well. 

Convalescence. — The  catheters  were  not  removed  for  six  days,  and  for 
four  days  there  was  considerable  hemorrhage  from  the  bladder  (as  before 
operation).  Highest  temperature  was  102°,  but  on  the  fourth  day  the 
temperature  was  normal.  Urine  did  not  come  through  the  urethra  until 
the  sixteenth  day. 

February  22,  1904- — There  has  been  no  wetting  of  the  perineal  pad  for 
the  past  four  days.  The  patient  is  comfortable,  but  gets  up  three  times  at 
night  to  urinate.    His  condition  is  excellent.     He  is  discharged  to-day. 

April  19,  1904- — The  fistula  is  again  opened,  but  only  a  few  drops  escape 
through  it.     He  suffers  no  pain,  and  voids  urine  in  a  large  stream  at  in- 
tervals of  five  hours.     Erections  have  returned.     The  fistula  is  curetted. 
(It  closed  finally  three  months  after  the  operation.) 
May  19,  1904- — ^A  pin  point  fistula  is  still  present.     Urination  is  normal. 


204  Hugh  H.  Young. 

The  patient  goes  to  bed  at  10  o'clock  and  gets  up  at  6  o'clock  to  urinate  for 
the  first  time.  Sexual  powers  are  normal.  Catheter  passes  with  ease,  no 
residual  urine  present,  bladder  capacity  500  cc.  Urine  very  slightly  cloudy, 
acid,  a  few  pus  cells  and  bacilli  present. 

June  21,  1904- — The  patient  has  been  curetted  with  the  gimlet  twice. 
The  fistula  is  now  closed.    Urination  and  sexual  powers  normal. 

February  1,  1905. — Letter.  I  am  cured.  I  void  urine  four  times  during 
the  day  and  once  at  night,  one-half  pint  at  a  time. 

November  30,  1905. — Letter.  I  void  urine  once  at  night  and  four  or  five 
times  during  the  day.  Occasionally  I  suffer  pain  at  the  end  of  the  penis 
and  urination  is  slow.  Erections  and  sexual  powers  are  satisfactory.  I 
have  had  no  complication  since  the  operation. 

February  7,  1906.  The  patient  voids  once  during  the  night  and  at  inter- 
vals of  four  hours  during  the  day.  Micturition  free,  and  only  a  slight  pain 
occasionally  at  the  end  of  urination.  He  has  erections  and  occasionally 
intercourse,  but  the  amount  of  ejaculated  fluid  is  slight  and  ejaculation  is 
accompanied  by  a  smarting  sensation  in  the  perineum. 

Examination. — The  urinary  stream  is  large,  the  urine  cloudy,  acid,  con- 
tains a  very  few  pus  cells  and  no  bacteria.  The  cicatrix  is  firm.  Rectal 
examination  shows  no  prostatic  enlargement,  a  catheter  passes  with  ease 
and  finds  no  residual  urine.     The  bladder  capacity  is  600  cc. 

Pathological  report. — Specimen,  G.  U.  67,  consists  of  four  pieces  and 
weighs  31  gm.  The  median  lobe  is  almost  spherical,  about  1.7  cm.  in  diam- 
eter and  weighs  3  gm.  The  left  lateral  lobe  is  the  larger,  has  been  removed 
in  two  pieces  and  measures  4.5x4x2.5  cm.  The  right  lobe  is  about  2% 
cm.  in  diameter.  The  three  lobes  are  similar  in  character,  surface  irregu- 
larly lobulated,  cut  surface  showing  numerous  spheroids  with  moderate  di- 
latation of  the  acini.  There  is  no  mucous  membrane  nor  ejaculatory  ducts 
present. 

Microscopic  examination. — ^The  hypertrophy  is  a  moderately  glandular 
one,  the  acini  showing  a  tendency  towards  aggregation  in  areas.  The  acini 
are  moderately  dilated,  and  the  lumina  rather  complex.  Some  of  the 
acini  show  considerable  adenocystic  papillomatous  changes.  The  stroma 
is  rather  dense;  is  largely  made  up  of  connective  tissue,  although  here  and 
there  a  fair  amount  of  muscle  is  present.  The  arteries  show  a  mod- 
erate degree  of  thickening. 

Case  28. — Slight  enlargement  of  median  and  lateral  lobes.  Vesical  cal- 
culi. Litholapaxy.  Bottihi  operation.  Perineal  prostatectomy.  Com- 
bined operation  to  close  recto-urethral  fistula.  Cured.  Followed  two  years 
and  four  months. 

No.  379.    H.  S.,  age  75,  married,  admitted  April  11,  1903. 

Gomplauit. — "  Complete  retention  of  urine.    Catheterism — pain." 

Patient  had  gonorrhoea  ten  years  ago.  It  lasted  several  months,  but  was 
finally  cured  without  complications  arising.  No  bladder  trouble  until  three 
years  later.  Present  illness  began  seven  years  ago  with  nocturnal  incon- 
tinence of  urine.  During  the  next  three  years  the  bed  was  wet  almost 
every  night. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  205' 

About  four  years  ago  patient  had  difficulty  in  urination,  and  in  a  short 
time  retention  of  urine  came  on.  He  was  catheterized  and  since  then  has 
been  unable  to  urinate.  For  two  years  it  was  only  necessary  to  use  the 
catheter  twice  a  day,  but  for  the  past  two  years  he  has  suffered  gradually 
more  and  more  pain,  and  he  has  had  to  catheterize  himself  more  and  more 
frequently. 

8.  P. — The  patient  catheterizes  himself  four  times  in  24  hours.  Is  un- 
able to  void  naturally.  He  suffers  considerable  pain  in  the  bladder  partic- 
ularly when  it  is  emptied  by  the  catheter,  and  at  times  severe  pain  in  the 
rectum  and  urethra  which  is  increased  on  walking. 

Sexual  powers. — No  note  made. 

Examination. — The  patient  is  rather  emaciated,  but  with  lips  of  good 
color.  The  pulse  is  64  to  the  minute,  volume  good,  moderate  arterioscle- 
rosis.   Chest  and  abdomen  are  negative. 

Genitalia. — The  left  epididymis  is  enlarged  and  tender. 

Rectal. — The  prostate  is  slightly  enlarged,  contour  is  rounded,  consist- 
ence soft,  no  nodules  and  no  induration.  Right  seminal  vesicle  is  soft, 
the  left  slightly  indurated. 

Urinalysis. — Cloudy,  alkaline.  Sp.  gr.  1018.  IVIicroscopically,  pus  cells, 
blood,  and  bacteria. 

Cystoscopic  examination. — lA  coude  catheter  passes  easily  and  finds  230 
cc.  of  urine  present.  The  patient  has  complete  retention  of  urine.  The 
cystoscope  shows  four  stones,  two  small  and  two  fairly  large,  all  fairly 
smooth  and  white  in  color.  Study  of  the  prostatic  orifice  shows  a  small 
median  lobe  with  a  shallow  sulcus  on  either  side.  The  lateral  lobes  are 
very  little  enlarged,  and  there  is  no  cleft  between  them  in  front.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  can  be  felt  and  the 
thickness  in  median  portion  is  only  moderately  greater  than  normal. 

I.  Operation,  April  13,  1903. — Ether.  Litholapaxy.  The  largest  stone 
caught  had  a  diameter  of  about  3  cm.  Considerable  difficulty  was  experi- 
enced in  getting  the  calculi,  owing  to  the  trabeculated  condition  of  the 
bladder  and  the  middle  lobe  of  the  prostate,  but  as  no  "  clicks  "  were  fin- 
ally obtained  by  the  evacuating  tube  no  further  attempts  were  made. 

Convalescence. — The  patient  did  not  convalesce  well.     The  temperature 
rose  only  to  100.5°,  but  he  suffered  greatly  with  pain  so  that  the  retained 
catheter  had  to  be  withdrawn.    After  that  he  was  catheterized  every  three 
'Or  four  hours,  but  he  became  irrational  and  weak.     It  was  evident  that  an- 
other operation  was  necessary  to  relieve  the  prostatic  obstruction. 

II.  Operation,  April  24,  1903. — Bottini  operation.  Cocaine  and  morphia. 
Three  cuts  with  blade  No.  3.  A  posterior  median  1.8  cm.  long,  right  lat- 
eral 2  cm.  long,  left  lateral  2.2  cm.  long.  There  was  very  little  hemorrhage 
and  the  patient  suffered  little.  A  catheter  was  fastened  in  the  penis  for 
continuous  drainage. 

Convalescence. — The  patient  convalesced  poorly.  He  had  a  slight  fever, 
suffered  considerable  pain,  voided  with  difficulty  and  had  considerable  re- 
sidual urine  for  which  catheterization  was  necessary.    For  .many  days  he 


206  Hugh  H.  Young. 

was  uremic  and  irrational  and  had  a  severe  bronchitis.  He  was  treated 
by  active  hydrotherapy  and  was  kept  in  a  wheel-chair  as  much  as  possible. 
He  finally  left  the  hospital  June  1,  rational,  but  very  weak,  voiding  urine 
in  small  amounts,  but  still  dependent  upon  a  catheter. 

February  1,  1904- — 'The  patient  has  been  unable  to  void  urine  and  has 
had  to  catheterize  himself  twice  daily.  He  has  suffered  severely  from 
pain  which  was  worse  when  he  was  on  his  feet,  and  as  a  result  has  re- 
mained in  bed  continually.  Examination  showed  a  prostate  very  little 
larger  than  normal  with  a  finger  in  the  rectum.  The  surface  was  irregu- 
lar and  the  consistence  hard.  A  silver  catheter  entered  with  ease  and 
found  a  large  bladder.  Careful  searching  failed  to  reveal  a  calculus.  With 
finger  in  rectum  and  catheter  in  urethra  the  tissues  between  the  two  were 
very  little  greater  than  normal.  Perineal  prostatectomy  was  advised,  al- 
though the  patient  was  extremely  weak. 

III.  Operation,  February  1,  1904. — Spinal  anesthesia.  Perineal  prosta- 
tectomy by  the  usual  technique.  Two  very  small  lateral  lobes  and  a  small 
median  bar  were  excised  with  considerable  difficulty  owing  to  their  fibrous 
character  and  adhesions  to  the  capsule,  urethra  and  bladder.  A  tear  was 
made  in  the  urethra,  but  no  mucous  membrane  was  removed.  The  blad- 
der was  carefully  searched  with  metal  instruments  and  no  stone  was 
found.  The  wound  was  closed  as  usual  with  the  exception  that  a  gauze 
pack  was  placed  between  the  posterior  surface  of  the  prostate  and  rectum 
which  was  not  examined  for  a  tear  and  the  levator  muscles  were  not 
drawn  together  with  catgut  sutures.  The  lateral  cavities  were  also  packed 
with  gauze  and  double  catheter  drainage  was  supplied.  The  anesthesia 
was  perfect.  There  was  considerable  shock  after  the  operation  and  intra- 
venous transfusion  of  1000  cc.  salt  solution  was  given. 

Convalescence.— T\ie  patient  reacted  well,  had  no  fever  and  suffered  no 
pain.  On  the  day  following  the  operation  bubbles  of  gas  passed  out 
through  the  wound,  and  after  the  gauze  was  removed  on  the  third  day 
fecal  matter  escaped  through  the  wound.  He  convalesced  slowly,  but  was 
able  to  void  naturally  and  without  pain.  The  rectal  fistula  did  not  close 
and  urine  escaped  into  the  rectum  and  gas  into  the  urethra.  He  left  the 
hospital  on  March  28,  much  improved  in  general  health. 

Octo'ber  9,  1904- — ^The  patient  continues  to  have  pain,  especially  at  the 
end  of  urination,  and  the  rectal  fistula  is  still  present.  Examination  with 
the  cystoscope  shows  three  calculi,  one  of  moderate  size  in  the  bladder.  No 
prostatic  enlargement  was  present.  Urine  is  voided  very  frequently,  and 
most  of  it  passes  into  the  rectum.     The  patient  is  weak  and  emaciated. 

IV.  Operation,  Novem'ber  10,  1904- — Ether.  Suprapubic  cystotomy  for 
drainage.  Perineal  operation  to  close  rectal  and  urethral  fistulse  and  to 
remove  vesical  calculi.  The  patient  was  first  placed  in  the  Trendelenberg 
position,  the  bladder  opened  through  a  small  incision  and  the  calculi  re- 
moved. Examination  showed  no  fistula  in  the  bladder  and  no  prostatic 
obstruction.  The  vesical  wall  was  then  closed  around  a  large  rubber  drain- 
age tube  and  the  patient  placed  in  the  lithotomy  position.    The  rectal  and 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  207 

the  urethral  openings  were  exposed  through  incisions  in  the  old  scar.  The 
rectal  opening  was  small  (less  than  1  cm.  In  diameter)  and  connected  di- 
rectly with  the  anterior  portion  of  the  prostatic  urethra.  After  excision  of 
scar  tissue,  the  rectal  wound  was  closed  with  interrupted  sutures  of  fine 
silk  and  reinforced  by  a  second  row  of  fine  silk  and  another  row  of  catgut. 
The  urethral  wound  was  also  closed  with  fine  silk  sutures,  and  the  ca,vity 
between  the  two  was  lightly  packed  with  gauze  and  the  skin  wound  was 
partly  closed  with  catgut.  The  patient  stood  the  operation  well  and  con- 
valesced satisfactorily.  The  suprapubic  drain  was  kept  in  place  for  about 
four  weeks  until  the  perineal  wound  had  healed  completely.  The  rectal 
and  urethral  fistula  healed  per  primam  and  after  the  removal  of  the  supra- 
pubic drain  this  wound  closed  rapidly  and  normal  urination  was  estab- 
lished through  the  penis. 

Fehruary  1,  1905. — Letter.  I  void  urine  naturally,  retaining  it  six  hours 
during  the  night  and  about  three  hours  during  the  day.  I  have  a  slight 
irritation  in  the  urethra  but  no  pain.  I  have  no  erections.  My  health  is 
fairly  good  and  I  consider  myself  cured  by  the  operation. 

February  13,  1906. — The  wounds  have  remained  closed  and  there  is  no 
fistula.  During  the  day  I  do  not  void  urine  for  three  or  four  hours,  but 
for  some  reason  after  retiring  after  10  p.  m.,  I  awake  at  1  a.  m.  to  urinate 
and  after  that  I  am  awakened  every  two  hours  with  a  desire  to  urinate. 
My  general  health  is  fair,  but  I  am  getting  old.    I  do  not  have  erections. 

May  11,  1906. — Letter.  I  void  urine  naturally,  three  or  four  times  during 
the  day,  and  not  until  the  latter  part  of  the  night.  I  am  then  wakeful  and 
void  frequently.  I  suffer  no  pain.  I  do  not  have  erections.  My  general 
health  is  good,  and  I  have  gained  in  weight.     I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  86,  consists  of  the  prostate  re- 
moved in  six  pieces,  and  weighing  in  all  about  15  gm.  Each  lateral  lobe 
was  removed  in  two  pieces  and  they  are  about  equal  in  size.  The  median 
lobe  is  in  two  pieces.  The  surfaces  are  irregular,  considerably  torn,  and  on 
section  are  rough  and  fibrous  with  here  and  there  dilated  acini  and  evident 
gland  tissue  is  seen.  There  is  no  arrangement  in  spheroids  in  some  of 
these  pieces,  but  in  others  it  is  present. 

Microscopic  examination. — The  hypertrophy  is  of  a  rather  mixed  char- 
acter, there  being  considerable  areas  in  which  hypertrophy  is  of  a  fibro- 
muscular  nature,  and  again  other  areas  in  which  the  acini  are  numerous, 
and  show  the  picture  presented  by  the  usual  glandular  hypertrophy.  The 
stroma  contains  a  large  amount  of  muscle,  this  being  sometimes  arranged 
in  definite  bundles.  In  the  more  glandular  areas  the  muscle  is  not  so  evi- 
dent, although  it  is  fairly  abundant.  There  is  considerable  round  celled 
infiltration  in  the  stroma.  The  arteries  show  a  moderate  degree  of  arterio- 
sclerosis. 

Case  29. — Considerable  enlargement,   lateral  and  median  lobes.     Seven 
calculi.    Patient  in  poor  condition.     Cured.    Followed  27  months. 
No.  549.    A.  D.,  age  75,  widowed,  admitted  February  11,  1904. 
Complaint. — "  Difficulty  in  urination,  catheterism." 
He  never  had  gonorrhoea. 


208  Hugh  H.  Young. 

Present  illness  began  six  years  ago  with  diflBculty  of  urination  and  grad- 
ually got  worse  until  complete  retention  of  urine  came  on  five  years  ago. 
He  was  then  catheterized  three  times,  but  did  not  again  require  it  until 
two  years  later,  when  he  used  the  catheter  four  times.  After  that  the 
catheter  was  employed  once  in  every  two  or  three  months  until  three 
months  ago,  since  which  time  he  has  used  the  catheter  from  three  to  four 
times  a  day.  He  is  now  able  to  void  very  little  without  the  catheter.  Dur- 
ing urination  he  occasionally  has  pain  in  the  bladder  and  urethra.  He  has 
not  lost  weight  and  his  general  health  is  excellent.  Erections  of  the  penis 
are  still  present  occasionally,  but  he  has  not  attempted  intercourse  for 
years. 

Examination. — The  patient  is  rather  feeble  in  appearance,  his  arteries 
are  markedly  sclerotic,  but  his  pulse  is  regular  and  of  good  quality,  and 
100  to  the  minute.     The  heart,  lungs,  and  abdomen  are  negative. 

Rectal  examination. — 'The  prostate  is  considerably  enlarged  forming  a 
smooth  elastic  mass  about  the  size  of  a  small  orange.  The  seminal  vesicles 
are  not  palpable,  there  is  no  induration,  no  glands  and  the  rectum  is  not 
adherent. 

Cystoscopic  examination. — A  catheter  passes  with  ease,  but  produces 
hemorrhage.  The  cystoscope  came  in  contact  with  a  calculus  in  the  pos- 
terior portion  of  the  prostatic  urethra.  There  were  present  also  three  or 
four  calculi  in  the  bladder,  but  it  was  impossible  to  get  a  satisfactory  ex- 
amination on  account  of  hemorrhage. 

Operation,  Fet)ruary  16,  190-'). — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  prostate  was  removed  in  three  large  and  one  small 
pieces  and  weighed  91  grams.  A  small  tear  was  made  in  the  left  lateral 
wall  of  the  urethra,  but  the  bladder  and  the  ejaculatory  ducts  were  not  in- 
jured. After  removal  of  the  tractor  a  finger  was  inserted  and  a  small 
stone  was  found  in  the  prostatic  urethra  and  removed.  A  stone  forceps 
was  then  introduced  in  the  bladder  and  six  calculi  extracted  through  the 
prostatic  urethra.  The  four  larger  calculi  measured  2  x  1.5  x  1.5  cm.  in 
size.  The  lateral  cavities  were  packed  with  gauze.  A  double  catheter 
drain  was  put  in  the  bladder  and  the  wound  closed  as  usual.  The  patient 
stood  the  operation  well.  Pulse  at  the  end  of  the  operation  108.  Infusion 
on  table  continued  on  return  to  ward. 

Convalescence. — The  patient  convalesced  slowly,  but  had  very  little  fever. 
The  temperature  for  the  first  17  days  being  normal,  it  then  rose  to  102° 
and  was  accompanied  by  nausea  and  vomiting,  but  fell  to  normal  the  next 
day.  The  tubes  and  gauze  were  removed  on  the  8th  day.  The  patient  was 
out  of  bed  on  the  14th  day,  but  was  weak  and  his  appetite  was  poor.  After 
the  third  week  he  improved  slowly  but  steadily  and  was  discharged  on 
the  S9th  day.  At  that  time  patient  was  able  to  retain  urine  for  four  hours, 
voided  freely,  and  had  no  incontinence.  The  wound  was  closed,  and  the 
bladder  held  240  cc.  The  fistula  afterwards  reopened  and  did  not  close 
finally  until  three  months  after  leaving  hospital. 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  209 

March  15,  1904. — The  patient  voids  twice  during  the  night.  There  is 
still  a  slight  leakage  through  the  perineum.  A  silver  catheter  passes  with 
ease  and  finds  only  5  cc.  residual  urine.  The  bladder  is  contracted,  holding 
only  1G5  cc.  on  forced  distention.  The  perineal  fistula  will  admit  a  fine 
probe. 

March  22,  1904. — The  bladder  has  been  forcibly  distended  by  hydraulic 
pressure  daily.  Under  this  treatment  the  capacity  has  increased  from 
165  to  240  cc.  in  one  week.  He  now  voids  eight  times  in  24  hours.  The 
perineal  fistula  is  healed  and  ho  has  complete  control  of  urine  which  is 
quite  purulent  and  contains  numerous  bacilli. 

May  20.  1904-  Letter  I  can  hold  my  urine  six  hours  at  night  and  four 
hours  in  the  day.  I  have  not  used  a  catheter  and  urination  is  satisfactory. 
The  fistula  is  not  closed  and  a  few  drops  escape  at  each  urination.  I  suf- 
fer no  pain,  have  no  erections.    My  general  health  is  good. 

February  1,  1905.  Letter.  I  am  cured.  Can  void  urine  naturally,  gen- 
erally four  times  during  the  day  and  twice  at  night,  half  a  pint  at  a  time. 

November  30,  1905. — The  wound  is  healed  and  the  urination  is  normal. 
I  am  entirely  cured.  My  general  health  is  excellent  and  I  work  on  the 
farm.     I  get  up  twice  at  night  to  urinate. 

May  20,  1900.  I^etter.  I  void  urine  naturally,  three  or  four  times  during 
the  day  and  once  or  twice  at  night,  and  in  normal  quantities.  I  have  no 
pain,  no  erections,  and  have  had  no  complications  nor  treatment.  My  gen- 
eral health  is  good,  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  68,  consists  of  three  lobes  of 
the  prostate  which  have  been  removed  in  seven  pieces  and  weighs  91  gm. 
The  left  lateral  lobe  consists  of  four  pieces  and  weighs  33  gm.  It  is  fairly 
smooth,  round,  and  on  section  shows  considerable  gland  tissue  with  a  fair 
number  of  dilated  ducts,  and  a  small  amount  of  stroma.  The  right  lateral 
lobe  was  removed  in  one  piece,  measuring  4x5x3  cm.  in  size,  and  is  simi- 
lar in  appearance  to  the  left.  The  median  lobe  has  been  removed  in  two 
pieces  and  weighs  2G  gm.  It  is  more  glandular  and  has  more  dilated  acini 
than  the  lateral  lobes.  No  mucous  membrane,  no  ejaculatory  ducts,  no 
calculi. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  and  much 
the  same  character  in  all  three  lobes.  The  amount  of  stroma  varies  in 
different  portions,  but  as  a  whole  the  gland  tissue  is  in  excess.  In  the 
lateral  lobes  there  are  areas  of  marked  cystic  dilatation,  and  the  majority 
of  the  acini  are  moderately  dilated.  In  places  there  is  the  usual  com- 
plexity of  the  alveoli  and  evidence  of  glandular  proliferation.  In  the 
acini,  which  have  undergone  cystic  degeneration,  the  epithelium  is  for  the 
most  part  of  a  low  cuoboidal  type.  In  the  middle  lobe  the  alveoli  do  not 
show  as  much  evidence  of  cystic  degeneration  as  in  the  lateral  lobes,  but 
the  ducts  are  considerably  dilated.  The  stroma,  which  is  rather  dense  in 
character,  is  composed  mostly  of  fibrous  tissue,  although  in  areas  the 
muscle  predominates.    No  areas  of  prostatitis  noted. 


210  Eugli  H.  Young. 

Case  30. — Moderate  enlargement  of  median  and  lateral  lobes.  Large  di- 
verticulum, with  small  orifice  on  anterior  wall  of  bladder.  Excision  of 
diverticulum.     Perineal  prostatectomy.     Cure.     Followed  27  months. 

No.  558.  J.  R.  B.,  age  63,  married,  admitted  February  18,  1904. 

Complaint. — "  Difficulty  and  frequency  of  urination.  Pressure  in  the 
lower  abdomen." 

He  lias  never  had  gonorrhcea  or  previous  urinary  trouble. 

Present  illness  began  about  two  years  ago  with  slight  difficulty,  and  fre- 
quency of  urination.  Since  then  there  has  been  a  gradual  increase  in  the 
symptoms  of  obstruction  and  occasionally  he  has  attacks  of  pain,  dull  in 
character,  located  in  the  perineum  and  neck  of  the  bladder,  and  lasting  only 
a  short  time.  At  times  he  voids  three  or  four  times  an  hour,  but  at  other 
times  goes  as  long  as  two  hours  without  urinating.  These  attacks  of  great 
frequency  are  not  associated  -with  pain,  but  seem  to  be  due  to  a  constant 
pressure  in  the  lower  abdomen  and  a  desire  to  urinate  which  persists  after 
micturition.    Sexual  powers  are  normal,  but  not  entirely  satisfactory. 

Examination. — Patient  is  a  healthy  looking  man.  Very  slight  arterio- 
sclerosis. The  pulse  is  irregular  and  a  presystolic  murmur  is  present  at 
the  apex.  Percussion  of  the  abdomen  shows  considerably  distended  blad- 
der reaching  almost  to  the  umbilicus  and  an  area  of  dulness  extending  up- 
ward and  outward  from  the  bladder  into  the  right  iliac  fossa.  The  geni- 
talia are  normal.  The  prostate  is  moderately  enlarged,  smooth,  elastic, 
soft,  without  induration  or  nodules.  The  seminal  vesicles  are  not  palpable. 
The  urine  is  clear  and  acid.  Sp.  gr.  1020.  No  albumin,  no  sugar.  The 
prostatic  secretion  contains  actively  motile  spermatozoa,  lecithin  bodies,  a 
great  number  of  large  granule  cells  and  no  pus  cells. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  with- 
draws 1200  cc.  residual  urine.  Study  of  the  prostatic  orifice  shows  a  mod- 
erate hypertrophy  of  both  lateral  lobes  and  a  small  median  bar.  The  blad- 
der is  moderately  trabeculated.  On  the  anterior  wall  of  the  bladder  about 
2  cm.  distance  from  the  median  line  on  the  right  side  is  the  orifice  1  cm. 
in  diameter  of  a  large  diverticulum.  The  cystoscope  can  easily  be  intro- 
duced through  this  opening  and  shows  a  large  extra-vesical  cavity  lined 
with  smooth  mucous  membrane  and  extending  far  backward  along  the 
right  lateral  wall  of  the  bladder.     There  is  no  cystitis  present. 

Note. — Owing  to  the  position  of  the  diverticulum  and  the  small  orifice 
it  was  thought  best  to  remove  it  at  the  same  time  that  prostatectomy  was 
done. 

Operation,  February  22,  1904. — Ether.  With  the  patient  in  the  Trendelen- 
berg  position  the  anterior  wall  of  the  bladder  was  exposed  in  the  median 
line.  Diverticulum  was  found  to  be  of  great  size  filling  the  space  between 
the  bladder  and  right  wall  of  the  pelvis,  the  sacrum  and  the  pelvic  peri- 
toneum. Its  walls  were  very  thin  and  it  contained  probably  500  cc.  of 
urine.  It  communicated  with  the  bladder  by  a  narrow  orifice  about  4  cm. 
above  the  prostato-vesical  juncture  and  2  cm.  from  the  median  line  on  the 


study  of  lJj.5  Cases  of  'Perineal  Prostatectomy.  211 

right  side  of  the  anterior  wall  of  the  bladder.  The  neck  of  the  sac  was 
caught  between  two  clamps,  divided  and  then  easily  enucleated.  The  ori- 
fice was  then  inverted  and  closed  by  a  purse  string  catgut  suture.  The 
bladder  was  not  opened  and  the  suprapubic  muscular  wound  was  closed 
with  a  small  area  for  drainage.  The  patient  was  then  placed  in  the  litho- 
tomy position  and  the  prostate  enucleated  by  the  usual  technique.  The 
lateral  lobes  measured  3x4x5  cm.  in  size  and  the  median  bar  about  3  cm. 
in  diameter.  The  ejaculatory  ducts  and  urethra  were  preserved  with  the 
exception  of  a  small  tear  that  was  made  in  removing  the  median  bar 
through  the  left  lateral  cavity.  The  wound  was  closed  as  usual  with  double 
tube  drainage.  There  was  very  little  hemorrhage  and  the  patient  stood  the 
operation  well. 

Convalescence. — Patient  reacted  well.  Evening  temperature  between 
100°  and  101°  for  seven  days,  after  that  normal.  The  gauze  was  removed 
from  the  perineal  wound  on  the  third  day  and  the  tubes  on  the  fourth 
day.  The  suprapubic  gauze  was  removed  on  the  fifth  day,  and  there  was 
no  leakage  of  urine  through  the  suprapubic  wound.  On  the  tenth  day 
urine  was  still  coming  through  the  perineal  wound,  but  the  patient  had 
perfect  control  and  could  retain  his  urine  for  six  hours. 

March  19,  1904- — Patient  voids  urine  every  three  or  four  hours  in  the 
day  and  five  to  six  hours  at  night.  The  perineal  wound  is  healed  (closed 
on  the  26th  day).  Urine  is  cloudy  and  contains  pus  cells  and  bacilli.  Pa- 
tient was  treated  actively  by  urotropin  and  intravesical  irrigations  of 
1  :  5000  nitrate  of  silver  with  the  hope  of  removing  the  vesical  infection, 
but  after  one  month's  treatment  the  urine  still  contained  bacilli.  He  was 
then  discharged,  25th  day. 

May  10,  1904- — (The  patient  has  used  intravesical  irrigations  of  boric 
acid.  Urotropin  and  helmatol  internally.  Urine  passes  freely,  but  still 
contains  numerous  bacilli.  A  catheter  passes  with  ease.  Residual  urine 
150  cc.  The  cystoscope  shows  a  slight  fold  of  mucous  membrane  at  the 
vesical  orifice  in  the  median  portion  of  the  prostate.  No  prostatic  lobes 
present.  At  the  site  of  the  diverticular  orifice  is  a  small  scar.  With  the 
finger  in  the  rectum  and  cystoscope  in  the  urethra  the  amount  of  tissue  is 
no  greater  than  normal. 

May  31,  1904- — 'Urine  is  voided  freely,  a  pint  at  a  time.  A  catheter  passes 
wihout  meeting  any  obotruction  and  finds  only  5  cc.  residual  urine. 

Decemher  12,  1905. — The  patient  voids  urine  freely  at  intervals  of  five 
or  six  hours.  Often  does  not  arise  during  the  night  to  urinate.  There 
is  no  incontinence,  but  occasionally  a  slight  urgency.  Erections  and  power 
of  intercourse  have  returned.  A  catheter  passes  easily,  residual  urine  30 
cc,  bladder  capacity  550  cc.    Urine  slightly  cloudy,  with  pus  and  bacteria. 

May  8,  1906. — ^I  void  urine  naturally  at  normal  intervals,  never  more  than 
once  at  night,  as  much  as  a  pint  at  a  time.    I  have  no  pain.    Sexual  inter- 
course is  not  entirely  satisfactory,  the  power  does  not  seem  to  be  as  strong. 
My  general  health  is  good  and  I  consider  myself  cured. 
Vol.  XIV.— 15. 


212  Hugli  H.  Young. 

Case  31. — Moderate  hypertrophy  of  lateral  lobes.  No  stone.  No  catheter 
life.    Cure. 

No.  565.    R.  W.  B.,  age  65,  admitted  February  26,  1904. 

Complaint. — "  Frequent  and  difficult  micturition." 

He  had  gonorrhoea  at  the  age  of  20,  but  was  thoroughly  cured. 

The  present  illness  began  about  five  years  ago  with  a  sudden  complete 
retention  of  urine  which  was  relieved  by  a  hot  bath,  his  physician  being 
unable  to  pass  a  catheter.  For  three  days  he  had  constant  dribbling  of 
urine,  but  then  passed  a  small  calculus  and  after  that  the  urine  came  freely. 
His  physician  found  the  prostate  enlarged  at  that  time,  and  since  then  his 
symptoms  have  grown  gradually  worse.  The  catheter  has  only  been  used 
three  times  and  always  produced  considerable  hemorrhage.  Pain  has  been 
very  slight,  and  there  has  been  very  little  loss  of  weight.  Sexual  powers 
have  diminished  considerably  during  the  past  two  years,  and  he  has  had 
no  erections  for  several  months.  He  now  urinates  every  hour  during  the 
night  and  every  two  hours  during  the  day  without  hemorrhage  and  only 
slight  pain. 

Examination. — ^A  sturdy  looking  man  with  soft  arteries  and  good  pulse. 
The  heart,  lungs,  genitalia  and  abdomen  are  negative.  The  prostate  is 
moderately  enlarged,  smooth,  slightly  indurated  and  uniform  in  consist- 
ence. It  is  adherent  laterally,  and  tender  on  pressure.  The  seminal  vesi- 
cles are  not  palpable.  A  catheter  passes  with  ease  and  finds  180  cc.  residual 
urine.  The  bladder  is  irritable  and  contracted  and  will  take  only  195  cc. 
of  fiuid.  The  cystoscope  passed  easily,  but  hemorrhage  was  produced, 
making  the  examination  unsatisfactory.  Urine  acid,  cloudy,  albumen  in 
considerable  amount,  no  sugar.    Microscopically,  pus  cells,  no  bacteria. 

Preliminary  treatment. — Water  in  abundance,  urotropin  and  catheteriza- 
tion three  times  daily.    800  cc.  was  withdrawn  at  one  time. 

Operation,  March  3,  1904- — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Two  considerably  enlarged  lateral  lobes  were  easily  enucleated, 
a  small  tear  being  made  in  the  urethra.  There  was  no  median  lobe  present 
and  no  calculus.     The  ejaculatory  ducts  were  preserved. 

The  wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs 
for  the  lateral  cavities.  The  patient  was  infused  on  the  table  and  stood 
the  operation  well.  Pulse  at  the  end  115.  Continous  irrigation  on  return 
to  the  ward. 

.Convalescence. — The  patient's  pulse  was  rather  weak  for  several  hours 
after  the  operation,  but  was  good  the  next  day.  The  temperature  rose  to 
101°  on  the  day  after  the  operation,  and  during  the  next  nine  days  there 
was  an  evening  temperature  generally  between  100°  and  101°  and  once 
reaching  103°,  after  that  it  was  practically  normal.  On  the  third  day  the 
patient  was  stupid  and  slightly  delirious  and  was  infused.  The  gauze  was 
removed  on  the  third  day  and  the  tubes  on  the  fourth  day.  Urine  began 
to  flow  through  the  urethra  on  the  sixth  day,  and  on  the  14th  day  the  pa- 
tient was  able  to  retain  urine  for  four  hours.  He  was  discharged  from 
the  hospital  on  the  27th  day  in  excellent  condition  with  a  pin-point  fistula 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  213 

in  the  perineum.  An  attempt  was  made  to  pass  a  catheter,  but  obstruction 
was  met  with  in  the  region  of  the  membranous  urethra.  Filiforms  were 
then  tried  without  success.  The  patient  was  able  to  void  in  a  good  stream, 
and  there  was  no  evidence  of  stricture. 

April  16,  190 Jf.  (Seventh  week  later). — I  have  been  improving  daily. 
Only  a  few  drops  of  urine  pass  through  the  fistula.  I  can  hold  urine  for 
five  hours,  have  no  pain,  sleep  well  and  have  a  good  appetite. 

May  11,  1904- — Letter.  I  can  hold  my  urine  five  hours  during  the  day, 
but  void  about  every  two  hours  at  night.  The  wound  is  closed  and  I  can 
empty  my  bladder.  I  pass  one  pint  of  urine  at  a  time  in  a  large  stream 
and  without  pain.    I  have  had  no  erections.    My  general  health  is  good. 

February  1,  1905. — ^I  can  void  urine  normally  and  am  cured.  I  void 
urine  five  times  during  the  night,  but  only  three  times  during  the  day 
and  in  large  amounts,  about  330  cc.  at  a  time.  I  have  no  pain.  Erections 
have  been  absent  since  several  months  before  the  operation.  My  general 
health  is  good. 

April  5,  1905. — 'Letter  from  physician.  The  patient  died  a  few  days  ago 
of  pneumonia.  During  his  illness  urine  contained  pus,  red  blood  corpuscles 
and  hyaline  casts.    His  urinary  trouble  was  relieved  by  the  operation. 

Pathological  report. — The  specimen,  G.  U.  69,  consists  of  the  lateral  lobes 
of  the  prostate,  each  removed  in  one  piece  and  weighs  in  all  26  gm.  The 
right  lobe  is  the  larger  and  measures  5  x  3  x  2.  cm.,  weighs  18  gm.,  is  encap- 
sulated, and  on  section  shows  numerous  large  spheroids  with  considerable 
cystic  dilatation  and  moderate  amount  of  stroma.  The  left  lobe  weighs 
8  gm.,  and  measures  2.5  x  2.3  x  2  cm.  It  is  similar  in  character  to  the 
right,  but  is  firmer  and  shows  few  dilated  acini.  A  portion  of  the  floor  of 
the  urethra  has  been  removed  with  the  right  lateral  lobe,  but  the  ejacu- 
latory  ducts  are  not  present.    No  calculi. 

Microscopic  examination. — The  hypertrophy  in  both  lobes  is  of  the 
glandular  type  with  dilatation  of  the  acini,  with  numerous  intraacinous 
off-shoots  from  the  peripheral  wall  and  occasional  areas  of  cystic  degen- 
eration. The  adenomatous  tissue  is  much  in  excess  of  the  stroma  which 
contains  more  connective  tissue  than  muscle.  A  few  small  areas  of  pros- 
tatitis. 

Case  32. — Slight  enlargement  of  lateral  and  median  portions.  Vesical 
calculus.  Contraction  of  bladder.  Restriction  of  normal  urination.  Con- 
traction of  bladder  persists.    Followed  two  years. 

No.  569.    W.  P.  R.,  age  64,  widower,  admitted  March  5,  1904. 

Complaint. — "  Frequency  of  urination  and  pain." 

Gonorrhoea  at  the  age  of  22,  no  gleet  or  stricture  following. 

Present  illness  began  18  months  ago  with  a  slight  smarting  pain  during 
urination.  Two  months  later  his  bladder  became  very  irritable  and  uri- 
nation frequent.  Seven  months  ago  he  had  hematuria  for  a  week,  and 
since  then  frequency  and  pain  have  been  on  the  increase. 

/S.  P. — Urination  is  very  frequent,  at  times  every  half  hour.    During  and 


214:  Hugh  H.  Young. 

at  the  end  of  urination  there  is  a  severe  pain  in  the  bladder  and  urethra. 
His  general  health  is  fairly  good.  His  sexual  desire  has  been  absent  for 
six  months  and  previous  to  this  he  has  only  occasionally  had  intercourse. 

Examination. — Patient  is  a  pale,  rather  feeble-looking  man.  The  chest, 
abdomen  and  genitalia  are  negative. 

Rectal. — ^The  prostate  is  very  little  enlarged,  flat,  indurated,  but  smooth. 
Seminal  vesicles  are  palpable,  enlarged  and  slightly  indurated. 

Urinalysis. — Cloudy,  acid,  1023,  considerable  albumin,  microscopically, 
pus,  epithelium,  red-blood  corpuscles  and  bacilli. 

Cystoscopic. — The  catheter  passes  with  ease  and  find  very  little  residual 
urine.  The  bladder  is  very  irritable,  much  contracted  and  holds  only  65 
cc.  The  cystoscope  shows  an  irregular,  chronically  inflamed  prostatic  mar- 
gin with  a  verj'  small  rounded  median  enlargement.  The  lateral  lobes  are 
not  at  all  intravesically  enlarged.  Just  back  of  the  prostatic  orifice  is  a 
fairly  large  stone,  rough  and  brownish  in  color.  It  was  impossible  to  ex- 
amine the  bladder  satisfactorily.  With  finger  in  rectum  and  cystoscope 
in  urethra  the  median  portion  of  the  prostate  is  slightly  increased. 

Operation,  March  7,  1904- — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Lithotomy  through  the  wound.  Both  lateral  lobes  were  little 
if  at  all  enlarged,  hard,  very  adherent  and  difficult  to  enucleate.  The  me- 
dian portion  of  the  prostate  was  so  small  that  it  could  not  be  engaged  with 
the  blade  of  the  tractor,  but  was  drawn  by  the  index  finger  into  the  left 
lateral  cavity  and  enucleated  there  after  division  of  close  adhesion  to  the 
mucous  membrane.  The  left  lateral  wall  of  the  urethra  was  then  divided 
longitudinally,  the  vesical  sphincter  dilated,  forceps  introduced  and  a  cal- 
culus 3  X  2  X  1^2  cm.  in  size  removed.  Double  catheter  drainage  and  light 
packing  for  the  lateral  cavities.  No  suture  of  the  urethral  incision,  clos- 
ure of  the  skin  as  usual.  Continuous  irrigation  and  infusion.  Patient  stood 
the  operation  well.    Pulse  at  end  116. 

Convalescence.— The  patient  had  no  fever  until  11  days  after  the  opera- 
tion He  convalesced  well.  The  continuous  irrigation  was  kept  up  for  24 
hours,  the  gauze  was  removed  on  the  second  day  and  the  tubes  on  the  third 
day.  The  patient  was  out  of  bed  on  the  fourth  day.  The  fistula  closed  on 
the  11th  day.  On  the  13th  day  he  was  able  to  retain  urine  for  three  hours, 
but  passed  some  blood.  On  the  14th  day  there  was  considerable  hemor- 
rhage so  that  a  retention  catheter  was  inserted.  Following  this  he  had  a 
chill,  temperature  reaching  103°.  On  the  18th  day  another  hemorrhage 
occurred  and  the  catheter  again  was  inserted.  After  this  he  had  no  fur- 
ther bleeding  and  left  the  hospital  on  the  28th  day.  At  that  time  the  urine 
was  clear,  wound  closed,  general  condition  of  the  patient  good.  Micturi- 
tion at  intervals  of  about  two  hours. 

April  20,  1904- — 'Urination  is  still  frequent  and  examination  shows  that 
the  bladder  only  holds  190  cc. 

June  1,  190Jf. — ^The  patient  has  been  treated  by  hydraulic  dilatation  of 
the  bladder  and  its  capacity  is  now  310  cc.  Urine  is  voided  in  a  large 
stream  without  difficulty,  at  intervals  of  two  and  one-half  hours. 

July  9,  1904- — The  bladder  now  contains  390  cc. 


study  of  IJfS  Cases  of  'Perineal  Prostatectomy.  215 

Septeynber  3,  1904- — A  catheter  passes  with  ease  and  finds  no  residual 
urine.  The  bladder  capacity  is  300  cc.  He  has  used  no  intravesical  irriga- 
tions or  dilatations  for  several  months.    He  is  advised  to  begin  again. 

February  1,  1905. — I  void  urine  naturally  five  or  six  times  during  the 
day  and  three  or  four  times  during  the  night  without  pain.  I  am  cured, 
but  have  had  no  erections.    This  disturbs  me  greatly. 

March  20,  1905. — A  fine  opportunity  was  afforded,  and  I  found  that  my 
sexual  powers  were  as  good  as  ever.  My  youth  has  been  renewed.  I  now 
believe  in  prostatectomy. 

February  17,  1906. — Letter.  I  void  urine  naturally,  but  quite  often,  ow- 
ing t  -)  contracture  of  the  bladder.  I  generally  urinate  four  or  five  times 
during  the  night,  but  I  have  no  pain  and  sometimes  pass  a  glass  full  of 
urine  at  a  time.  I  have  erections  occasionally  and  have  had  very  satisfac- 
tory sexual  intercourse.  I  have  not  continued  to  dilate  my  bladder  as  you 
suggested.  My  general  health  is  very  good,  and  I  have  gained  many  pounds 
in  weight. 

Pathological  report. — iThe  specimen,  G.  U.  72,  consists  of  three  pieces 
representing  the  lateral  and  median  portions  of  the  prostate,  and  weighs 
in  all  about  8  gm.  The  right  lateral  lobe  measures  2.5x2x2  cm.,  is  some- 
what irregular,  but  fairly  smooth,  and  on  section  shows  gland  tissue  with 
considerable  intervening  stroma,  some  dilated  ducts,  no  spheroids  and  a 
fairly  thick  capsule.  The  left  lobe  is  smaller  than  the  right,  measuring 
only  2x2x1.3  cm.,  but  is  similar  to  the  right  in  character.  The  median 
bar  is  a  small  bit  of  tissue  1.5  x  .8  x  .6  cm.  in  size,  and  seems  quite  fibrous. 
No  mucous  membrane,  no  ejaculatory  duct  removed.  An  oval  calculus 
about  3x2x1.5  cm.  in  size  is  present. 

Microscopic  examination. — In  both  lateral  lobes  the  hypertrophy  is  a 
richly  glandular  one,  the  stroma  being  comparatively  small  in  amount. 
The  acini  are  moderately  dilated  and  in  areas  show  cystic  dilatation. 
There  are  the  usual  intra-acinous  projections  which  in  places  assume  a 
papillomatous  type.  There  is  present  quite  a  marked  prostatitis  with 
numerous  pus  cells  in  the  lumina  of  the  ducts,  and  quite  marked  epithelial 
proliferation  and  desquamation.  The  stroma  contains  considerably  more 
connective  tissue  than  muscle,  and  there  is  quite  extensive  round  cell  and 
polynuclear  cell  infiltration  with  some  areas  of  chronic  inflammatory  tissue 
formation.  In  the  middle  bar  the  glandular  element  is  very  much  ex- 
ceeded by  the  stroma.  The  acini  are  filled  with  proliferating  and  desqua- 
mated epithelial  cells.  The  microscopic  picture  seems  to  differ  from  the 
normal  only  in  the  fact  that  there  is  present  quite  a  marked  prostatitis. 

Case  33. — Small  pedunculated  median  lobe.  Vesical  calculus.  Con- 
tracted bladder.  Catheter  life.  Result:  Normal  urination.  Frequency  and 
pain  owing  to  contraction,  possibly  calculus.  Lived  one  year  after  opera- 
tion.   Death:  Cause?    No  autopsy. 

No.  582.  G.  R.  B.,  age  77,  married.  Seen  in  Rochester,  New  York,  March 
11,  1904. 

Complaint. — "Difficulty,  frequency  and  painful  urination." 


216  Hugh  H.  Young. 

No  history  of  gonorrhoea  or  previous  urinary  trouble.  Present  illness 
began  six  years  ago  with  slight  difficulty  and  frequency  of  urination  which 
increased  gradually  until  he  began  the  use  of  a  catheter  two  years  ago. 
Since  then  he  has  been  unable  to  void  urine  naturally,  and  he  now  has  to 
use  a  catheter  every  hour.  He  suffers  considerably  from  pain  at  the  end 
of  urination. 

Examination. — The  patient  is  a  very  weak-looking  man.  He  is  pale  and 
pulse  is  poor.  Chest  and  abdomen  negative.  The  prostate  is  only  slightly 
hypertrophied,  considerably  indurated  and  tender.  A  catheter  passes  with 
ease.  Retention  of  urine  is  complete.  Bladder  capacity  small  and  bladder 
very  irritable.  The  cystoscope  shows  a  small  pedunculated  median  lobe, 
a  slight  intravesical  hypertrophy  of  both  lateral  lobes,  and  a  vesical  cal- 
culus of  medium  size. 

Operation,  March  11.  lOOJ/. — Spinal  anesthesia  with  cocaine  grains  %. 
Prostatectomy  by  the  usual  technique.  The  lateral  lobes  w^ere  only  slightly 
enlarged.  It  was  impossible  to  engage  the  middle  lobe  with  the  tractor 
or  with  the  finger.  As  the  urethra  had  to  be  dilated  to  remove  the  calculus, 
it  was  thought  best  to  remove  it  through  the  dilated  prostatic  urethra, 
which  was  done  by  means  of  a  clamp.  It  proved  to  be  about  3  cm.  long 
and  2  cm.  in  diameter.  A  stone  3x4x2  cm.  in  size  was  then  removed 
through  the  urethra.  The  urethra  and  ejaculatory  ducts  were  preserved 
intact.  The  usual  closure  was  employed  with  double  drainage  tubes  for 
the  bladder.  Patient  did  not  suffer  pain  in  the  operation  upon  the  pros- 
tate and  his  condition  at  the  end  was  good.  Continuous  irrigation  and  a 
submammary  infusion  of  salt  solution  were  given  on  return  to  the  room. 

Convalescence. — The  patient  reacted  well.  The  tubes  and  gauze  were 
removed  on  the  third  day.    No  complications. 

Letter  from  Dr.  Howard,  June  5,  1904- — The  patient  looks  very  well.  The 
fistula  has  closed  and  he  urinates  freely.  He  walks  about  the  ward  and  has 
a  normal  pulse  and  temperature.  Sounds  are  passed  occasionally.  The  pa- 
tient urinates  every  half  an  hour  night  and  day,  but  the  stream  is  large, 
and  he  thinks  he  can  empty  his  bladder.  His  chief  complaint  is  severe 
pain  just  back  of  the  glans  penis.  He  has  no  erections,  but  these  were  ab- 
sent before  operation. 

Letter,  Febriuiry  1,  1905. — I  void  every  hour  and  about  two  ounces  at  a 
time.  Pain  is  almost  continually  present  in  the  penis.  I  do  not  use  a 
catheter.  I  am  physically  very  weak  on  account  of  the  severe  pain  and 
frequency  of  urination. 

Note. — His  physicians  reported  that  there  was  no  residual  urine  present 
and  no  stone,  but  the  bladder  was  markedly  contracted  and  markedly  in- 
flamed. They  were  advised  to  try  dilatation  of  the  bladder  by  hydraulic 
pressure,  but  apparently  very  little  success  attended  their  efforts,  and  pa- 
tient died  in  the  spring  of  1905.  No  autopsy  was  obtained,  but  the  obstruc- 
tion to  urination  had  apparently  been  completely  removed. 

Pathological  report. — Specimen  G.  U.  97.  The  hypertrophy  consists  about 
equally  of  gland  tissue  and  stroma,  the  relative  amounts  varying  in  dif- 
ferent areas.     There  seems  but  slight  tendency  to  form  spherical  lobules. 


study  of  1J/.0  Cases  of  'Perineal  Prostatectomy.  21T 

Microscopic  examination. — The  acini,  as  a  rule,  do  not  show  the  com- 
plexity which  one  sees  in  more  glandular  prostates.  They  are,  however, 
for  the  most  part  dilated,  and  here  and  there  show  small  cystic  forma- 
tion. The  stroma  is  rather  compact,  and  contains  more  connective  tissue 
than  muscle.  There  are  quite  numerous  areas  of  interstitial  round  cell 
and  polynuclear  cell  infiltration. 

Case  34. — Slight  enlargement  of  median  and  lateral  loies.  200  cc.  re- 
siduum. Diabetes  m^ellitus.  Complication:  rectal  necrosis,  fistula.  Sec- 
ondary closure  of  rectum.    Cure.    Folloiced  26  months. 

No.  581.  J.  K.,  age  65,  married.  Operated  upon  in  Rochester,  N.  Y., 
March  11,  1904. 

Complaint. — "Difficulty  and  frequency  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  10  years  ago  with  slight  difficulty  of  urination. 
Since  then  there  has  been  a  gradual  increase  in  the  difficulty  and  frequency 
of  micturition.  He  was  catheterized  first  seven  months  ago  and  since  then 
has  used  the  instrument  at  least  once  daily,  but  has  not  had  complete  re- 
tention of  urine. 

iS.  P. — The  patient  catheterizes  himself  twice  daily.  After  four  or  five 
hours  he  begins  to  void,  the  interval  being  every  two  hours  until  cathe- 
terized again.  He  has  very  little  pain  and  his  general  health  is  good. 
Sexual  powers  are  weakened.  Erections  are  present  occasionally  and  in- 
tercourse possible,  but  ejaculations  are  very  premature. 

Examination. — The  patient  looks  well,  his  lips  are  of  good  color,  and 
the  arteries  are  only  slightly  thickened.  Chest,  abdomen  and  genitalia 
negative. 

Rectal. — The  prostate  is  slightly  enlarged,  does  not  bulge  into  the  rec- 
tum, is  smooth,  but  distinctly  hard.     The  seminal  vesicles  are  negative. 

Cystoscopic  examination  was  not  made.  A  coude  catheter  passes  with 
ease  and  finds  200  cc.  residual  urine. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1025,  no  albumin.  Sugar  in  small  but 
definite  amount. 

Xote. — 'In  view  of  the  presence  of  sugar  the  operator  would  have  put  the 
patient  upon  anti-diabetic  treatment  before  performing  prostatectomy  had 
the  patient  been  in  Baltimore.  His  general  condition,  however,  was  ex- 
cellent, there  were  no  symptoms  of  diabetes  and  his  physician  considered 
the  disease  of  slight  import.     Operation  was  therefore  agreed  to. 

Operation,  March  11,  1904- — Chloroform.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  are  very  little  larger  than  normal  and 
quite  adherent  in  the  deeper  portion,  but  were  fairly  easily  enucleated  each 
in  one  piece.  The  middle  lobe  could  not  be  engaged  with  the  blade  of  the 
tractor  and  that  instrument  was  withdrawn.  With  a  finger  in  the  urethra 
a  small  pedunculated  median  lobe  was  pushed  into  the  left  lateral  cavity 
and  there  enucleated  without  removing  any  of  the  mucous  membrane  cov- 
ering it.    The  middle  lobe  measured  1  x  1  x  .5  cm.  in  size.    The  ejaculatory 


218  Hugh  H.  Young. 

ducts  were  preserved  and  only  one  small  tear  was  made  In  the  urethra. 
The  wound  was  closed  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  Examination  of  the  posterior  portion  of  the  wound  with 
the  finger  showed  that  no  tear  had  been  made  in  the  rectum  (but  the  lev- 
ators were  not  drawn  together  as  is  now  done).  The  patient  stood  the 
operation  well.  Continuous  irrigation  and  infusion  on  return  to  room. 
Instructions  were  given  to  start  the  gauze  on  the  next  day,  to  remove  them 
on  the  third  day  and  the  tubes  on  the  fourth  day.  The  operator  left 
Rochester  five  hours  after  the  operation. 

Convalescence. — Complete  notes  not  obtained.  When  the  tubes  were  re- 
moved on  the  fourth  day  a  rectal  fistula  was  discovered. 

March  25,  1904- — Letter.  The  patient  is  doing  well,  and  the  fistula  is 
smaller,  but  there  is  quite  a  hole  in  the  rectal  wall  just  above  the  sphinc- 
ter. The  urine  escapes  through  the  perineum,  but  no  feces  or  gas  escape 
through  the  urethra.     The  wound  looks  well. 

On  April  7  an  incision  was  made  in  the  bulbous  urethra  and  a  rubber 
catheter  inserted  through  it  into  the  bladder  for  continuous  drainage.  It 
was  removed  after  12  days,  and  for  one  week  there  was  no  escape  of  urine 
through  the  original  perineal  wound,  and  the  rectal  fistula  was  greatly 
contracted. 

May  1,  1904- — The  perineal  fistula  has  opened  again,  but  it  is  very  small 
and  does  not  leak  until  the  bladder  becomes  distended.  He  voids  urine 
every  three  hours  and  has  no  dribbling. 

October  6,  1904- — The  patient  presents  himself  for  examination  in  Balti- 
more. He  voids  urine  at  normal  intervals,  arising  only  once  during  the 
night.  There  is  no  difliculty  in  urination,  but  the  urine  escapes  partly 
through  the  penis,  through  the  rectum  and  through  the  perineal  fistula. 
Gas  escapes  through  the  urethra,  but  never  any  fecal  matter.  He  has  been 
on  anti-diabetic  diet  for  four  months  and  his  urine  has  been  free  from 
sugar.    His  general  health  is  good. 

Examination. — At  the  apex  of  the  perineal  incision  is  a  small  urinary 
sinus.  With  finger  in  rectum  a  small  rectal  fistula  is  found  just  above  the 
sphincter  ani.  The  outlines  of  the  prostate  cannot  be  made  out.  The 
urine  is  acid,  slightly  purulent  and  contains  2%  sugar. 

Preliminary  treatment. — The  urine  contained  very  little  sugar,  the  sp. 
gr.  from  1020  to  1027.  The  patient  was  kept  on  anti-diabetic  diet  for  12 
days  previous  to  operation.  The  specific  gravity  varied  from  1015  to 
1020,  there  was  no  sugar  or  acetone  present.  For  two  days  previous  to  the 
operation  bicarbonate  of  soda,  grains  15,  was  given  every  four  hours. 

Operation,  October  18,  1904.— Ether.  Suprapubic  cystotomy  for  drain- 
age. Closure  of  rectal  and  urethral  fistula  through  perineal  incision.  A 
very  small  suprapubic  incision  was  made.  The  finger  showed  a  normal 
prostatic  orifice  and  no  foreign  body.  A  large  drainage  tube  was  inserted, 
and  the  bladder  closed  round  it.  The  patient  was  then  placed  in  the  litho- 
tomy position,  and  a  probe  passed  through  the  fistula  into  the  rectum  and 
another  into  the  urethra.     Incisions  were  then  made  in  the  old  scar  and 


study  of  145  Cases  of  ■Perineal  Prostatectomy.  219 

the  flstulse  excised.  The  urethral  opening  was  found  to  be  about  1  cm. 
long,  that  into  the  rectum  was  smaller.  After  excising  all  cicatricial  tissue 
the  rectal  opening  was  closed  with  a  double  layer  of  mattress  sutures  of 
fine  silk.  The  urethral  opening,  which  was  found  to  be  in  the  membranous 
urethra,  was  similarly  closed.  The  levator  ani  muscles  were  drawn  to- 
gether over  the  rectum  with  interrupted  sutures  of  catgut.  The  wound 
was  lightly  packed  and  partially  closed  with  interrupted  sutures  of  cat- 
gut. The  patient  was  infused  on  the  table  and  stood  the  operation  well. 
Pulse  at  the  end  95. 

Convalescence. — The  patient  reacted  well.  On  the  day  after  the  opera- 
tion he  was  given  an  infusion  1000  cc.  salt  solution  containing  40  grains 
of  bicarbonate  of  soda.  After  that  he  received  30  grains  of  bicarbonate  of 
soda  every  four  hours  and  a  lead  and  opium  pill,  and  morphia  in  small 
amounts  for  seven  days.  The  gauze  was  removed  on  the  4th  day.  There 
had  been  no  escape  of  urine,  all  of  which  came  through  the  suprapubic 
tube.  The  bowels  were  not  moved  until  the  13th  day,  after  he  had  re- 
ceived castor  oil  and  Rochelle  salts  by  mouth  and  high  retained  oil  enema. 
The  patient  had  been  fairly  comfortable  up  to  the  12th  day  when  he  began 
to  complain  of  pain.  Some  fecal  matter  came  through  the  perineal  wound 
and  after  that  there  was  also  an  escape  of  urine  through  the  perineum. 
The  suprapubic  drainage  tube  was  not  removed,  and  after  nine  days  there 
was  no  further  escape  of  feces  or  urine  through  the  perineum,  and  the 
perineal  wound  healed  by  granulation.  The  suprapubic  tube,  however, 
was  not  removed  until  the  38th  day.  The  patient  left  the  hospital 
on  the  55th  day.  At  that  time  patient  voided  naturally,  without  pain. 
Rectal  examination  showed  the  closure  of  the  rectal  fistula,  the 
suprapubic  and  perineal  wounds  were  also  closed.  Silver  catheter  passed 
with  ease,  there  was  no  residual  urine  present,  no  stone,  the  bladder  was 
contracted,  but  its  exact  size  not  determined.  Urine  was  clear,  acid,  con- 
tained no  sugar,  but  pus  cells  and  bacilli  in  moderate  number.  The  pa- 
tient has  been  eating  meat,  eggs,  onions,  cabbage,  and  asparagus. 

February  1,  1905. — Letter.  I  void  urine  naturally  at  intervals  of  three 
hours,  have  no  pain  and  consider  myself  cured.     I  have  had  no  erections. 

Novem'ber  30,  1905. — I  void  urine  once  at  night  and  about  every  two 
hours  in  the  day,  suffer  no  pain.  I  have  erections  at  times,  but  have  not 
had  intercourse.  The  wounds  have  remained  closed.  My  general  health  is 
excellent  and  I  have  gained  in  weight. 

May  10,  1906. — Letter.  I  void  urine  naturally  at  regular  intervals,  arise 
about  once  at  night  to  urinate.  Have  no  pain,  no  erections.  My  general 
health  is  good,  I  have  gained  in  weight.  The  wounds  have  remained 
closed,  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  71,  consists  of  three  lobes 
of  the  prostate  each  removed  in  one  piece,  and  weighs  in  all  about 
10  gm.  The  median  lobe  is  somewhat  pear-shaped,  and  measures  1.2  x  1 
xl.5  cm.  One  lateral  lobe  measures  2.5  x  2.5  x  1.5  cm.  and  the  other  about 
2  cm.  in  diameter.     Each  of  the  lobes  is  globular  in  shape,  encapsulated. 


220  Hugh  E.  Young. 

and  on  section  is  fairly  homogeneous  with  very  little  stroma  in  places;  in 
other  places  it  is  more  pronounced  with  spheroid  formation.  No  areas  of 
induration.  No  mucous  membrane  has  been  removed.  The  ejaculatory 
ducts  are  not  present. 

Microscopic  examination. — The  gland  tissue  is  very  much  in  excess 
of  the  stroma  and  for  the  most  part  arranged  in  lobules.  The  acini 
are  for  the  most  part  considerably  dilated  with  occasional  cystic  degenera- 
tion of  an  acinus.  The  acini  show  the  usual  complexity  and  proliferation. 
The  stroma  is  compact,  the  connective  tissue  being  slightly  in  excess  of 
the  muscle.  Some  corpora  amylacea  are  seen.  A  few  small  areas  of  pros- 
tatitis are  present.    The  hypertrophy  is  of  the  same  type  in  all  three  lobes. 

Case  35. — Moderate  Jiypertrophy  of  median  and  lateral  loies.     Cured. 

No.  585.     S.  S.,  age  72,  married,  admitted  March  21,  1904. 

Complaint. — "  Difficulty  of  urination.      Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  four  years  ago  with  difficulty  and  frequency  of 
urination  which  gradually  increased  until  two  years  ago  when  complete 
retention  of  urine  set  in  and  patient  had  to  be  catheterized.  For  the  next 
six  months  the  catheter  was  used  four  or  five  times  during  the  day.  After 
that  for  a  time  he  voided  naturally,  but  during  the  past  18  months  the 
catheter  has  been  necessary. 

8.  P. — The  patient  uses  the  catheter  five  times  in  24  hours,  retention  of 
urine  being  complete.  He  secretes  about  10  pints  of  urine  in  24  hours,  and 
usually  finds  two  pints  each  time  with  the  catheter.  He  has  not  suffered 
pain  nor  hematuria  and  his  general  health  has  been  good.  Erections 
present,  sexual  powers  normal. 

Examination. — The  patient  is  a  sturdy-looking  man.  Lips  and  mucous 
membranes  of  good  color.  Both  lungs  are  emphysematous.  The  heart  is 
difficult  to  outline,  but  the  sounds  are  clear,  though  the  rhythm  is  exceed- 
ingly irregular. 

Rectal  examination. — The  prostate  is  moderately  hypertrophied,  rounded, 
smooth,  elastic,  soft.     The  seminal  vesicles  cannot  be  reached. 

Cystoscopic  examination. — 'A  large  coude  catheter  passes  with  ease.  The 
bladder  capacity  is  large,  retention  of  urine  is  complete.  The  cystoscope 
encounters  hemorrhage,  making  the  examination  unsatisfactory.  The 
presence  of  a  fairly  large  middle  lobe  and  slight  bilateral  intravesical  hy- 
pertrophy is  made  out.  It  is  impossible  to  examine  the  bladder  satis- 
factorily. 

Urinalysis. — Sp.  gr.  1012,  acid,  albumin  a  trace,  microscopically,  pus  and 
bacteria. 

Operation,  March  22,  1904. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  patient  was  a  very  large  man  and  the  perineum  very  thick 
and  the  prostate  deep.  Each  lateral  lobe  was  removed  in  two  pieces.  The 
middle  lobe  was  drawn  by  the  tractor  into  the  left  lateral  cavity  and  enu- 
cleated without  removing  any  mucous  membrane.    Examination  with  the 


study  of  lJf.5  Cases  of  ■Perineal  Prostatectomy.  231 

finger  in  the  urethra  showed  no  remaining  hypertrophied  tissue.  The  ure- 
thra was  torn,  but  no  mucous  membrane  was  removed  and  the  floor  and 
ejaculatory  ducts  were  preserved  intact.  An  infusion  was  given  on  the 
table,  the  wound  was  closed  as  usual  with  double  tube  drainage  and  light 
packs  for  the  lateral  cavities.  Condition  at  the  end  of  the  operation  was 
excellent,  pulse  being  95.  Continuous  vesical  irrigation  was  instituted  on 
return  to  ward. 

Convalescence. — The  patient  reacted  well,  highest  temperature  was  100° 
on  the  day  following  the  operation,  and  after  that  it  was  practically  normal. 
The  gauze  was  removed  on  the  second  day,  and  the  tubes  on  the  third  day. 
There  was  fairly  considerable  bleeding  for  24  hours  after  the  operation 
and  the  patient  was  infused  a  second  time.  Pulse  did  not  rise  above  100, 
however.  Urine  passed  through  the  urethra  on  the  ninth  day,  interval  uri- 
nation having  been  present  for  several  days.  The  patient  was  up  in  a 
chair  during  the  first  week.  He  was  discharged  April  18  (27th  day).  He 
has  not  had  instrumentation.  His  condition  was  excellent,  could  retain 
urine  for  three  or  four  hours  and  only  a  small  amount  came  through  the 
fistula  which  was  not  yet  closed.    There  had  been  no  complications. 

May  20,  1904- — Letter.  I  urinate  every  hour  during  the  day  and  five 
times  at  night.  There  is  no  fistula.  I  void  half  a  pint  at  a  time  and  feel 
that  I  can  empty  my  bladder.  Urination  is  satisfactory,  I  have  no  pain 
and  I  have  not  used  a  catheter.  Urine  is  very  foul.  I  have  not  had  erec- 
tions.    My  general  health  is  fairly  good. 

Pathological  report. — ^The  specimen,  G.  U.  75,  consists  of  the  lateral  and 
median  lobes  of  the  prostate  removed  in  six  pieces,  and  weighing  in  all 
25  gm.  The  right  lobe  is  composed  of  two  pieces,  the  left  of  three  pieces, 
and  the  median  of  one  piece.  All  of  the  lobes  are  composed  of  large  sphe- 
roids, loosely  bound  together.  On  section  numerous  small  and  enlarged 
spheroids  are  seen.  The  median  lobe  measures  2  x  2  x  1.5  cm.,  and  con- 
sists of  a  globular  mass  about  1.5  cm.  in  diameter  upon  a  flat  base.  The 
consistence  is  everywhere  elastic,  and  the  section  shows  numerous  dilated 
acini.    No  calculi  and  no  areas  suggesting  malignancy  are  present. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with 
areas  of  considerable  cystic  dilatation  and  areas  of  rather  marked  glandu- 
lar proliferation.  The  stroma  is  formed  mostly  of  fairly  cellular  con- 
nective tissue,  although  here  and  there  is  some  embryonic  tissue.  The 
muscle  is  quite  insignificant  in  amount.  Some  endoglandular  prostatitis 
is  present,  with  occasional  infiltration  of  the  periacinous  stroma.  The 
blood  vessels  show  only  slight  thickening. 

Case  36. — Moderate  enlargement  of  lateral  lodes  of  prostate.  Residual 
urine  10  cc.  Bladder  contracted,  capacity  50.  Vesical  calculus.  Cured. 
Followed  two  years. 

No.  106.    J.  W.  L.,  age  72,  married,  admitted  March  29,  1904. 
Complaint. — ■"  Frequent  and  painful  urination." 
No  history  of  gonorrhoea. 


223  Hugh  H.  Young. 

Present  illness  began  about  five  years  ago  with  increased  frequency  of 
urination.  Shortly  afterwards  he  passed  a  small  calculus,  and  during  the 
next  six  months  20  more  calculi.  In  November,  1899,  he  came  to  the  hos- 
pital complaining  of  painful  and  frequent  urination  which  occurred  at 
least  four  times  every  night,  and  often  every  15  minutes. 

Examination  showed  a  slightly  enlarged  prostate,  but  the  catheter 
showed  no  residual  urine.  The  bladder  was  irritable  and  held  only  100 
CO.  He  was  carefully  searched  with  a  metal  searcher,  but  no  calculus  was 
detected.  Several  days  later  the  cystoscope  showed  a  large  oval  calculus 
in  a  pouch  back  of  the  interureteral  ligament.  On  December  24,  1899,  lith- 
olapaxy  was  performed  under  chloroform  anesthesia.  Considerable  diffi- 
culty was  experienced  in  catching  the  fragments  with  the  lithotrite  and 
the  operation  required  one  hour  and  a  half. 

January  15,  1901. — The  patient  has  reacted  well,  voids  urine  without 
pain,  at  intervals  of  every  two  hours.    He  is  discharged. 

March  29,  190Jf. — Eighteen  months  ago  the  patient  began  again  to  pass 
gravel.  He  now  voids  every  hour  in  the  night  and  every  15  minutes  in 
the  day.  The  stream  is  slow,  and  small,  but  he  suffers  no  pain,  no  hema- 
turia. He  has  had  no  erections  for  four  years,  his  general  health  is  good. 
Examination. — Patient  is  well  nourished,  lips  of  good  color.  Heart, 
lungs  and  abdomen  are  negative.    There  is  slight  arterio-sclerosis. 

Rectal. — The  prostate  is  considerably  enlarged  in  both  lateral  lobes. 
The  median  furrow  is  deep  and  wide,  and  the  notch  is  deep.  The  surface 
is  smooth,  consistence  soft,  no  tenderness.  The  seminal  vesicles  cannot 
be  felt. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1018,  no  sugar,  albumin  slight,  micro- 
scopically, pus  cells  and  bacilli. 

Cystoscopic. — A  coude  catheter  passes  easily,  residual  urine  10  cc,  blad- 
der capacity  50  cc.  The  lateral  lobes  of  the  prostate  are  moderately  hyper- 
trophied,  there  is  a  deep  cleft  between  them  in  front  and  be- 
hind. Resting  on  top  of  the  two  lateral  lobes,  with  the  cys- 
toscope looking  upward,  two  stones  are  seen,  as  shown  in  A. 
In  series  U,  when  the  handle  of  the  cystoscope  is  depressed  the  anterior 
cleft  becomes  shallow  and  the  calculi  occupy  the  larger  part  of  the  field. 
When  the  handle  of  the  cystoscope  is  elevated  the  calculi  disappear  from 
view  and  the  anterior  cleft  becomes  quite  deep  (2  and  3).  In  series  D, 
with  the  handle  depressed  a  deep  cleft  is  seen  posteriorly.  On  gradually 
elevating  the  handle  of  the  cystoscope  the  lateral  lobes  are  gradually  sep- 
arated and  a  median  fold  of  mucous  membrane  appears  and  finally  in  4  is 
the  only  thing  seen  at  the  prostatic  margin.  Examination  of  the  bladder 
was  unsatisfactory.  With  finger  in  rectum  and  cystoscope  in  urethra  there 
was  very  little  increase  in  the  median  portion  of  the  prostate. 

Operation,  March  4,  190^. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Removal  of  two  calculi  through  wound.  The  lateral  lobes 
were  removed  each  in  two  pieces.  After  removal  of  the  first  piece  on  each 
side  it  seemed  that  all  of  the  hypertrophied  tissue  had  been  removed. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  223 

Careful  examination,  however,  revealed  an  intravesical  lobule  higher  up 
on  each  side,  the  blades  of  the  tractor  having  slipped  beneath  them  at  the 
beginning  v?hen  traction  was  made.  By  pushing  the  tractor  further  into 
the  bladder,  depressing  and  rotating  the  handle,  it  was  possible  to  draw 
down  and  enucleate  these  intravesical  enlargements  without  tearing  the 
urethra  or  the  bladder.  The  median  portion  of  the  prostate  was  not  re- 
moved, being  very  little  hypertrophied.  The  tractor  was  then  removed 
and  the  left  lateral  wall  of  the  urethra  divided  longitudinally  with  scis- 
sors. The  bladder  orifice  was  dilated  with  a  uterine  dilator,  a  stone  for- 
ceps inserted  and  two  calculi  easily  extracted.  The  finger  was  inserted 
and  showed  a  very  small  bladder  and  no  remaining  prostatic  enlargement. 
The  wound  was  closed  as  usual  with  double  drainage  tubes,  and  light 
gauze  packs  for  the  lateral  cavities.  Infusion  and  continuous  irrigation. 
Patient  stood  the  operation  well,  his  pulse  at  the  end  being  90. 

Convalescence. — The  highest  temperature  was  100.8°  on  the  second  day, 
after  the  third  day  it  was  practically  normal.  Continuous  irrigation  was 
kept  up  for  24  hours.  The  gauze  was  removed  on  the  third  and  the  tubes 
on  the  fourth  day.  The  patient  was  out  of  bed  on  the  sixth  day.  Urine 
came  through  the  urethra  on  the  eighth  day  and  the  perineal  fistula  closed 
on  the  eleventh  day.  There  was  scarcely  any  incontinence  after  the  opera 
tion,  and  the  patient  was  discharged  on  the  20th  day,  voiding  urine  in  a 
large  stream,  every  three  hours  during  the  day  and  with  perfect  control. 

May  20,  1904- — I  void  urine  at  intervals  of  three  hours  during  the  day, 
and  four  and  one-half  at  night,  half  a  pint  at  a  time.  The  wound  is 
closed  and  I  feel  well. 

February  1,  1905. — Letter.  I  void  urine  naturally,  three  or  four  times 
during  the  day  and  twice  at  night.    I  have  no  pain,  no  erections. 

Novem'ber  30,  1905. — Letter.  I  urinate  three  or  four  times  during  the 
day  and  twice  at  night.  Half  a  pint  at  a  time.  Occasionally  partial  erec- 
tions occur,  not  suflicient  for  intercourse.  My  health  is  excellent  and  I 
consider  myself  cured. 

May  7,  1906. — Letter.  I  void  naturally  from  four  to  six  times  a  day,  and 
once  or  twice  at  night  when  I  drink  much  water.  The  largest  amount 
voided  at  one  time  is  about  one-third  of  a  pint.  I  have  no  pain,  no  erec- 
tions. I  have  had  no  complications,  and  my  general  health  is  good.  I 
have  gained  in  weight  and  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  76,  consists  of  the  two  lateral 
lobes  of  the  prostate,  each  removed  in  two  pieces,  and  weighing  in  all  21 
gm.  The  surfaces  of  the  specimens  are  irregularly  lobulated  and  of  uni- 
form consistency.  On  section  numerous  spheroids  are  seen,  but  very  few 
dilated  ducts,  the  consistence  being  more  homogeneous  than  usual.  The 
right  lateral  lobe  weighs  11  gm.,  and  measures  4.5  x  2.5  x  2  cm.  The  left 
lobe  weighs  10  gm.  and  measures  5x3x2  cm.  Two  smooth  white  calculi 
measuring  each  about  2.5  cm.  in  diameter  have  been  removed. 

Microscopic  examination. — The  hypertrophy  is  of  a  rather  glandular  ap- 
pearance with  arrangement  in  lobules  and  there  is  condensation  of  the 


224  Hugh  E.  Young. 

perilobular  tissue.  The  tissue  presents  nothing  but  the  usual  glandular 
hypertrophy  except  that  there  is  quite  extensive  prostatitis  present,  with 
glandular  proliferation  and  degeneration  of  the  epithelial  cells,  and  fairly 
extensive  round  cell  and  polynuclear  cell  infiltration  of  the  stroma  and 
the  formation  of  some  chronic  inflammatory  tissue.  In  many  of  the  ducts 
quite  numerous  pus  cells  are  present. 

Case  37. — Small  hard  prostate.  Sligfit  median  enlargement.  Multiple 
vesical  septa  and  diverticula.  Operation.  Cure.  Contracture  of  Madder, 
relieved  ty  hydraulic  dilatation. 

No.  591.    W.  B.  E.,  age  47,  married,  admitted  March  31,  1904. 

Complaint. — "  Irritable  bladder." 

The  patient  had  gonorrhoea  at  the  age  of  IS  and  following  it  gleet  and 
stricture. 

Was  married  at  the  age  of  27  and  his  wife  had  no  children. 

Present  illness  began  12  years  ago  with  frequency  and  diflBculty  of  uri- 
nation and  pain  in  the  back.  Four  months  later  an  encysted  calculus  was 
removed  by  Dr.  Fenger  of  Chicago  through  a  suprapubic  incision.  The 
suprapubic  sinus  did  not  heal  for  five  months,  but  after  that  the  patient 
was  free  from  symptoms  for  six  months.  Another  calculus  was  then 
found  and  removed  by  litholapaxy  and  the  patient  remained  well  for  three 
years.  He  was  then  catheterized  and  five  ounces  of  residual  urine  discov- 
ered. For  three  weeks  his  bladder  was  irrigated  through  a  catheter  with 
much  improvement.  After  that  he  was  treated  by  various  men,  and  at 
times  was  quite  well,  and  at  others  had  considerable  difficulty  and  fre- 
quency of  urination.  For  the  past  two  years  he  has  been  unable  to  work. 
Has  treated  himself  off  and  on  with  intravesical  irrigations  through  the 
catheter,  usually  finding  three  ounces  of  residual  urine  and  a  contracted 
bladder.  For  the  past  three  months  the  patient  has  catheterized  himself 
regularly  at  bed  time,  generally  withdrawing  seven  ounces  of  residual 
urine,  and  in  this  way  has  been  able  to  sleep  four  or  five  hours  before 
arising  to  urinate.  Urination  is  difficult  and  he  often  has  to  strain.  He 
voids  about  every  hour,  but  has  no  pain  except  when  urination  is  particu- 
larly difficult.  His  general  health  is  good.  His  sexual  powers  are  normal 
with  the  exception  that  ejaculation  is  somewhat  precocious. 

Examination. — The  patient  is  a  healthy  looking  man  with  lips  of  good 
color.  The  heart  and  lungs  are  negative.  Abdomen  negative  with  the  ex- 
ception of  an  old  suprapubic  scar. 

Rectal  examination. — The  prostate  is  slightly  emarged.  The  consistence 
is  quite  hard,  particularly  the  right  lateral  lobe  which  is  very  hard,  the 
surface  is  smooth  and  there  are  no  nodules.  The  seminal  vesicles  are  not 
palpable,  and  there  is  no  induration  in  this  region.  A  catheter  passes  with 
ease  and  finds  180  cc.  residual  urine.  Bladder  capacity  is  about  300  cc. 
The  cystoscope  shows  a  slight  hypertrophy  of  the  left  lateral  and  median 
portions  of  the  prostate  with  a  deep  cleft  between.  Th  right  lateral  lobe 
is  not  enlarged  and  there  is  no  cleft  between  the  lateral  lobes  in  front. 
The  trigone  is  drawn  behind  the  median  bar  so  that  it  is  impossible  to 


study  of  145  Cases  of  'Perineal  Prostatectomy.  225 

see  the  ureters.  Tlie  bladder  is  markedly  inflamed,  trabeculated  and  sev- 
eral prominent  irregular  septa  are  present,  and  between  these,  deep  pouches 
and  three  diverticula  with  large  orifices  are  seen.  The  diverticula  occupy 
the  two  lateral  walls  of  the  bladder,  and  there  is  apparently  no  danger  of 
constriction  of  the  orifices  or  of  pressure  upon  the  ureters.  With  the 
finger  in  the  rectum  and  cystoscope  in  the  urethra  a  definite  increase  in 
the  median  portion  is  found. 

Urinalysis. — Very  cloudy,  acid,  albumin  in  small  amount,  no  sugar. 
Microscopically,  pus  in  considerable  amount. 

Note. — The  patient  was  treated  by  catheterization  and  intravesical  irri- 
gation, prostatic  massage  and  urethral  dilatation  from  March  31  to  April 
19.  Under  this  treatment  the  bladder  became  less  irritable,  but  the  amount 
of  residual  urine  increased,  at  least  400  cc.  being  present.  Perineal  pros- 
tatectomy was  decided  upon,  although  there  was  very  little  enlargement 
present. 

Operation,  April  19,  IdOJf. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  very  small,  weighing  about  7  gm.  each. 
The  median  enlargement  was  even  smaller,  and  was  removed  with  the  as- 
sistance of  a  finger  in  the  urethra  through  the  right  lateral  cavity.  No 
other  enlargement  was  present.  Examination  of  the  bladder  with  the  fin- 
ger showed  a  broad  shallow  pouch  behind  the  interureteral  ligament,  be- 
hind which  there  was  a  transverse  septum;  the  diverticula  were  out  of 
reach.  The  ejaculatory  ducts,  urethra  and  bladder  were  preserved  intact. 
The  lateral  cavities  were  packed  with  gauze,  double  tube  drainage  for  the 
bladder  through  the  perineum  was  supplied  and  the  wound  closed  as  usual. 
There  was  very  little  hemorrhage  and  the  patient's  condition  was  excel- 
lent. 

Convalescence. — The  patient  reacted  well.  The  gauze  was  removed  on 
the  fifth  and  the  tubes  on  the  sixth  day.  He  was  walking  on  the  ninth  day 
and  on  the  thirteenth  began  to  void  through  the  penis.  On  the  sixteenth 
day  the  perineal  wound  did  not  leak  for  a  day.  Temperature  rose  to 
100.6"  on  the  day  after  the  operation,  but  after  that  it  was  practically 
normal. 

May  7,  1904. — The  perineal  wound  is  still  open.  The  patient  has  not 
been  instrumented  since  the  operation.  He  voids  his  urine  about  every 
three  and  one-half  hours.  Has  no  dribbling  and  no  pain.  Is  discharged 
from  the  hospital  to-day  (18th  day). 

June  1,  1904-—^S'maU  urinary  fistula  is  still  present  in  the  perineum. 
Examination  shows  that  it  is  extremely  small  and  will  not  admit  a  probe. 
The  small  fistula  gimlet  can  be  screwed  in  with  ease,  and  by  this  means 
the  fistula  is  thoroughly  curetted. 

June  7,  1904- — The  fistula  closed  at  once  after  the  curettement  with  the 
gimlet  and  there  has  been  no  leakage  for  a  week.  The  patient  is  drinking 
large  amounts  of  water  and  is  voiding  325  cc.  of  urine  at  a  time.  The 
stream  is  large  and  urination  is  entirely  satisfactory.  Erections  have  re- 
turned. A  catheter  passes  with  ease  and  finds  100  cc.  residual  urine.  The 
bladder  is  slightly  contracted.     The  patient  is  discharged. 


226  Hugh  H.  Young. 

'Note. — The  residual  urine  in  this  case  is  probably  due  to  the  diverticula 
which  have  not  the  muscular  power  to  empty  themselves,  but  can  be 
drained  by  a  catheter. 

June  28,  1904. — I  am  feeling  well,  but  the  wound  broke  open  on  the  way 
home. 

November  17,  190Jf. — My  wound  is  completely  healed,  it  closed  two 
months  ago.  I  have  gained  30  pounds  in  weight.  My  urine  is  still  quite 
cloudy  and  I  am  troubled  sometimes  with  frequency  of  urination. 

February  1,  1905. — I  can  void  urine  normally,  and  consider  myself  cured. 
I  have  not  used  a  catheter  or  sound  since  the  operation.  I  suffer  no  pain. 
Erections  have  returned  and  intercourse  is  normal.  I  urinate  three  times 
during  the  night  and  five  times  during  the  day.  My  general  health  is  ex- 
cellent. 

November  30,  1905. — I  void  urine  naturally  and  consider  myself  cured. 
I  do  not  arise  at  all  at  night  to  urinate  as  a  rule,  but  sometimes  once.  I 
void  about  250  cc.  at  a  time.  Suffer  no  pain.  Erections  and  intercourse 
are  normal.     My  fistula  is  closed  and  I  have  complete  control. 

February  27,  1906. — ^The  patient  returns  for  examination.  He  has  had 
no  treatment  since  his  discharge,  and  has  not  required  catheterization. 
He  has  been  able  to  void  without  difficulty  or  pain,  but  there  has  been  a 
gradual  shortening  of  the  interval  between  urinations,  and  he  now  arises 
four  or  five  times  at  night  to  urinate,  and  voids  every  two  hours  during 
the  day.    He  has  perfect  control,  and  no  dribbling  at  the  end  of  urination. 

Sexual  powers. — Erections  and  intercourse  are  normal.  (Just  as  strong 
as  before  operation.)  The  patient  looks  well,  and  the  wound  is  firmly 
closed.  Rectal  examination  is  negative.  The  urine  is  acid,  very  cloudy, 
sp.  gr.  1011,  and  contains  albumin  in  considerable  amount,  and  bacilli 
and  pus  cells. 

Cystoscopic. — A  silver  catheter  passes  with  ease  and  finds  only  30  cc. 
residual  urine.  The  bladder  is  contracted  and  admits  only  150  cc.  of  fluid. 
(The  patient  is  able  to  retain,  however,  over  200  cc.  of  urine.)  There  is 
no  stricture  present.  The  cystoscope  shows  no  enlargement  of  the  lateral 
lobes  and  no  sulci  between  them.  There  is  a  slight,  thin,  but  definitely  ele- 
vated median  fold  or  bar  with  a  slight  pouch  behind  it.  Study  of  the 
bladder  shows  that  the  diverticula  are  still  present,  but  apparently  much 
smaller  than  before  operation.  The  broad  transverse  ridge  on  the  pos- 
terior wall  with  a  pouch  in  front  and  with  two  diverticula  on  each  side 
is  seen.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is 
easily  felt,  and  there  is  no  increase  of  the  median  portion  of  the  prostate 
made  out.    The  lateral  lobes  are  much  smaller. 

March  17,  1906. — The  patient  has  been  treated  for  three  weeks,  the  blad- 
der being  dilated  twice  daily  by  hydraulic  pressure.  The  Kollmann  dilator 
has  been  used  about  10  times,  although  no  stricture  has  been  detected,  and 
it  has  been  easy  to  dilate  the  urethra  up  to  No.  37-F.  The  bladder  has 
gradually  enlarged  by  hydraulic  dilatations.  At  first  it  was  possible  to  get 
in  only  about  150  cc.  and  the  amount  voided  was  never  over  125  cc.    The 


study  of  llj-o  Cases  of  'Perineal  Prostatectomy.  237 

patient  is  now  able  to  void  325  cc.  at  one  time,  and  urinates  only  about 
twice  at  night,  and  at  intervals  of  four  hours  during  the  day.  A  cathetei 
finds  30  cc.  residual  urine.  Urine  is  still  quite  cloudy  and  contains  pus  and 
bacteria.     Patient  is  discharged  and  advised  to  continue  irrigations. 

Remark. — This  case  is  a  good  example  of  markedly  increased  frequency' 
of  urination  due  to  vesical  contraction. 

May  8,  1906. — Letter.  I  void  urine  naturally  about  six  times  during  the 
day  and  twice  at  night,  about  eight  ounces  at  a  time.  I  have  erections  and 
satisfactory  sexual  intercourse.  My  general  health  is  excellent,  and  I  con- 
sider myself  cured. 

Case  38. — Considerable  enlargement  of  median  and  less  of  lateral  lohes. 
Catheterism.  Pain,  douMe  epididymitis.  Operation.  Cure.  Folloiced  IS 
months. 

No.  613.  G.  T.  C,  age  65,  married,  admitted  April  28,  1904. 

Complaint. — "  Difficulty  of  urination  and  catheterism." 

The  patient  had  gonorrhoea  at  the  age  of  19;  a  light  attack  of  which 
was  easily  cured,  without  subsequent  stricture  or  gleet. 

Present  illness  began  about  10  years  ago  when  he  noticed  for  the  first 
time  a  slight  difficulty  in  urination.  After  that  there  was  a  slow  but  grad- 
ual increase  in  the  difficulty  and  frequency,  but  he  did  not  have  complete 
retention  until  two  years  ago.  He  did  not  require  the  catheter  again  until 
one  month  ago,  and  since  then  has  used  it  from  two  to  five  times  every 
day,  but  occasionally  has  been  able  to  void  small  amounts.  Ten  days  ago 
both  testicles  became  swollen.  He  still  has  erections,  but  his  sexual  powers 
are  sorhewhat  weakened. 

Examination. — The  patient  is  a  sturdy  looking  man  with  only  slight  ar- 
teriosclerosis. A  marked  aortic  stenosis  is  present.  Each  epididymis  is 
indurated  and  enlarged.  On  rectal  examination  the  prostate  is  found 
markedly  enlarged,  being  about  the  size  of  a  medium-sized  orange,  smooth, 
elastic  and  soft,  regular  in  contour  with  no  nodules  nor  induration.  The 
median  furrow  is  shallow  and  the  notch  is  replaced  by  a  prominence,  the 
upper  end  of  which  can  just  be  reached.  The  seminal  vesicles  can  not  be 
palpated.  Urine  acid,  cloudy,  and  contains  albumin,  pus  and  epithelial 
cells,  and  numerous  bacilli. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
100  cc.  residual  urine  (patient  says  he  usually  finds  500  cc. ).  The  cysto- 
scope  shows  a  large  median  lobe  with  a  deep  sulcus  on  each  side  of  it. 
The  lateral  lobes  do  not  project  far  into  the  bladder,  and  there  is  no  cleft 
between  them  in  front.  The  bladder  wall  is  considerably  trabeculated  and 
numerous  pouches  are  seen.  With  the  finger  in  the  rectum  and  cystoscope 
in  the  urethra  the  beak  could  not  be  felt  and  the  mass  between  the  two 
was  considerable. 

Preliminary   treatment. — Frequent    catheterization.      Large    amounts   of 
water  and  urotropin  by  mouth. 
Vol.  XIV.— 16. 


228  Hugh  H.  Young. 

Operation,  May  6,  1904. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  prostate  was  enucleated  in  four  pieces,  the  two  lateral 
lobes  each  in  one  piece,  and  the  median  lobe  in  two  pieces,  one-half  through 
each  lateral  cavity.  The  urethra,  ejaculatory  ducts  and  bladder  were  pre- 
'  served  intact.  There  was  only  a  moderate  amount  of  hemorrhage.  The 
wound  was  closed  as  usual  with  gauze  packing  for  the  lateral  cavities  and 
double  drainage  tube  for  the  bladder.  Submammary  infusion  was  given 
on  the  table  and  a  continuous  irrigation  for  the  bladder  was  given  for 
about  48  hours  after  the  operation. 

Convalescence. — ^The  patient  stood  the  operation  well.  The  gauze  was 
pulled  out  on  the  third  day  and  the  tubes  on  the  fourth.  The  fistula  closed 
three  weeks  after  the  operation,  and  the  patient  went  home  on  the  twenty- 
sixth  day.    Highest  temperature  101.6°  on  the  fourth  day. 

June  5,  1904- — The  patient  voids  at  intervals  of  from  four  to  six  hours. 
He  has  no  incontinence,  and  urination  is  normal.    Erections  have  returned. 

June  29,  1904- — ^The  patient  reports  urination  normal.  Sexual  desire  and 
erections  have  returned. 

September  22,  1904- — The  patient  goes  to  bed  at  9  o'clock,  arises  to  uri- 
nate at  9  a.  m. 

Noveinher  30,  1905. — Urination  is  normal  and  the  patient  is  able  to  retain 
urine  for  from  six  to  nine  hours.  He  has  had  no  instrumentation  since  op- 
eration and  voids  urine  in  a  large  stream.  Erections  are  the  same  as  be- 
fore operation  and  intercourse  is  indulged  in.  Has  had  no  complication 
since  operation. 

Pathological  report. — The  specimen,  G.  U.  285,  consists  of  five  pieces  of 
prostatic  tissue  representing  the  two  lateral  and  the  median  lobe.  Total 
weight  about  25  gm.  The  tissue  is  lobulated,  consistency  firm,  but  elastic. 
On  section  the  tissue  is  composed  of  spheroids  in  varying  sizes  with  mod- 
erate-sized interlacing  bands  of  denser  tissue.  The  ejaculatory  ducts  have 
not  been  removed.    No  calculus. 

Microscopic  examination. — 'The  hypertrophy  is  a  lobulated  moderately 
glandular  one  in  which  the  usual  picture  is  greatly  modified  by  infiamma- 
tory  changes.  Over  extensive  areas  the  acini  are  small,  separated  by  con- 
siderable bands  of  stroma,  and  about  the  acini  there  is  concentrically  ar- 
ranged considerable  fibrous  tissue.  The  gland  ducts  are  filled  with  pus 
cells,  and  degenerated  and  desquamated  epithelial  cells.  In  some  lobules 
where  the  prostatitis  is  absent  or  small  in  amount  the  gland  acini  are 
moderately  dilated  with  serrated  margin  and  lined  by  tall  cylindrical 
epithelium.  The  stroma  is  about  equal  in  amount  to  the  gland  tissue, 
and  it  contains  considerable  excess  of  connective  over  muscle  tissue. 
There  is  considerable  infiammatory  infiltration,  and  there  has  been  consid- 
erable inflammatory  hypoplasia.  The  microscopic  picture  has  been  much 
modified  by  the  extensive  prostatitis.  The  blood  vessels  for  the  most  part 
seem  practically  normal. 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  229 

Case  39. — Small  round  median  lobe.  No  lateral  enlargement.  Residual 
urine  JflO  cc.  Rectal  fistula  after  operation.  Closure  at  third  operation. 
Cure.    Followed  two  years. 

No.  630.     S.  M.  G.,  age  62,  widowed,  admitted  May  21,  1904. 

Complaint. — "  Difficulty  in  urination.    Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  about  eight  years  ago  with  slowness  in  starting 
urination.  After  voiding  a  small  amount  there  would  be  a  sudden  stop- 
page accompanied  by  pain,  but  after  a  little  while  he  would  be  able  to 
void  again.  The  difficulty  and  frequency  of  urination  gradually 
increased  and  two  years  ago  the  difficulty  was  intense.  In  March, 
1903,  the  patient  had  a  severe  attack  of  la  grippe,  and  after  that  the 
difficulty  of  urination  and  frequency  of  urination  were  very  great  for  two 
or  three  months.  Then  he  began  to  improve  and  by  November,  1903,  he 
was  able  to  void  urine  without  pain  at  intervals  of  from  six  to  eight 
hours.  A  month  later,  however,  after  a  severe  chill,  urinary  trouble 
again  became  very  distressing,  urination  being  very  frequent,  difficult  and 
painful.  About  January  15,  1904,  he  was  catheterized  by  his  physician 
and  14  ounces  residual  urine  obtained.  Since  then  he  has  used  the  cath- 
eter about  four  times  a  day.  Under  this  treatment  he  has  improved  con- 
siderably. 

S.  P. — At  present  the  patient  uses  the  catheter  night  and  morning.  After 
catheterization  he  does  not  void  for  three  hours,  but  thenceforth  voids 
every  hour  or  two  until  catheterized  again.  Urination  is  difficult,  and  he 
suffers  pain  which  is  located  in  the  neck  of  the  bladder,  and  is  worse  at 
the  end  of  urination. 

Sexual  powers. — Erections  are  present,  but  he  has  not  had  intercourse 
for  12  years. 

Examination. — The  patient  is  a  well  nourished  man  with  lips  of  good 
color.    Heart,  lungs  and  abdomen  are  negative.     Genitalia  negative. 

Rectal  examination. — The  prostate  appears  only  slightly  enlarged,  left 
lobe  being  a  little  larger  than  the  right.  It  is  smooth,  generally  indurated, 
but  not  of  stony  hardness.  No  nodules  are  to  be  felt,  and  the  seminal 
vesicles  are  soft.  Urine  cloudy,  acid,  sp.  gr.  1010;  trace  of  albumin,  no 
sugar.  Microscopically,  pus  cells  and  bacilli.  Prostatic  secretion  contains 
many  pus  cells,  few  normal  elements  and  no  spermatozoa. 

Cystoscopic  examination. — A  catheter  passes  with  ease  and  finds  470  cc. 
residual  urine.  The  cystoscope  shows  a  small  median  lobe  with  a  shallow 
sulcus  on  each  side,  the  lateral  lobes  are  not  intravesically  hypertrophied 
and  there  are  no  clefts  between  them  in  front.  The  bladder  is  markedly 
trabeculated,  showing  numerous  small  cellules  and  deep  pouches.  There 
is  no  foreign  body  and  a  cystitis  of  moderate  degree  is  present.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  can  be  easily  felt, 
and  the  tissue  in  the  median  portion  of  the  prostate  seems  only  moderately 
thickened. 


230  Hugh  H.  Young. 

Operation,  May  SI,  1904- — Ether.  Perineal  prostatectomy  by  the  usual 
technique  with  the  exception  that  the  rectum  was  not  examined  and  the 
levators  were  not  approximated.  The  lateral  lobes  were  only  slightly  en- 
larged, very  adherent  to  the  capsule  and  urethra,  but  were  successfully  re- 
moved each  in  one  piece  without  injury  of  the  mucous  membrane  or  blad- 
der. Attempt  was  made  to  engage  the  median  lobe  with  one  blade  of  the 
tractor,  but  owing  to  its  small  size  it  was  impossible,  the  tractor  was  then 
withdrawn  and  after  dilatation  of  the  urethra  with  a  glove  stretcher,  the 
index  finger  of  the  left  hand  was  inserted,  and  a  very  small,  slightly 
rounded  median  lobe  was  found  and  carried  with  difficulty  by  the  finger 
towards  the  left  lateral  cavity  where  it  was  removed  with  blunt  and  sharp 
periosteal  elevators.  A  small  bit  of  mucous  membrane  which  covered  its 
vesical  surface  was  removed,  but  the  urethra  and  ejaculatory  ducts  were 
left  intact.  The  wound  was  closed  with  double  drainage  tubes  for  the  blad- 
der; lateral  cavities  packed  with  gauze.  It  was  not  the  custom  then  to 
examine  the  rectum  at  the  end  of  the  operation  nor  to  approximate  the 
levator  muscles  and  neither  of  these  was  done,  otherwise  the  closure  was 
as  usual.  There  was  only  a  moderate  amount  of  hemorrhage  and  the  pa- 
tient stood  the  operation  well.  Continuous  irrigation  and  submammary 
infusions  were  both  given  on  the  table. 

Convalescence. — The  patient  reacted  well.  Pulse  at  end  of  operation  70. 
Temperature  on  night  following  operation  98.4°.  Continuous  irrigation 
was  discontinued  after  five  hours,  and  the  second  day  after  the  operation 
his  temperature  arose  to  108.8°.  The  patient  complained  of  a  severe  pain 
in  the  head  and  the  abdomen.  He  was  given  an  enema  at  6  p.  m.  and 
shortly  afterwards  complained  of  severe  pain  in  the  wound.  On  the  third 
day  he  continued  to  have  pain  in  the  abdomen  and  the  wound  and  received 
codeia  several  times  and  calomel.  His  temperature  was  104.4°.  All  gauze 
was  removed  on  the  third  day   (no  evidence  of  fecal  fistula  then). 

June  3. — Fourth  day.  The  patient  had  a  large  fluid  stool  to-day,  there 
was  a  considerable  discharge  of  feces  from  the  wound  when  the  bowels 
moved.  The  patient  still  complains  of  pain  in  the  wound.  The  drainage 
tubes  were  removed  to-day.  At  9  p.  m.  the  patient  received  a  large 
enema  through  a  rectal  tube  and  had  a  large  fluid  stool,  but  continued  to 
suffer  a  severe  pain  in  the  wound. 

June  9,  1904. — His  general  condition  is  improving,  and  the  patient  is  on 
his  feet  every  day.  He  has  had  several  stools  and  is  more  comfortable. 
The  urine  still  escapes  through  the  perineum. 

June  11,  1904- — ^Night  before  last  after  an  enema  given  with  a  large  rec- 
tal tube,  about  half  of  the  fluid  expelled  came  through  the  perineal  wound. 
The  patient  thought  that  gas  had  escaped  through  the  wound  on  the  day 
previous. 

July  1,  1904- — The  recto-urethral  perineal  fistula  persists.  All  the  urine 
comes  through  the  perineum  and  gas  and  feces  also  escape  through  it  and 
sometimes  through  the  urethra.     Examination  with  the  finger  shows  an 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  231 

opening  in  the  anterior  wall  of  the  rectum  about  one  inch  above  the  anus, 
and  large  enough  to  admit  the  end  of  the  finger.  Left  sided  epididymitis 
developed  June  18,  but  subsided  without  operation. 

Note. — In  reviewing  the  history  it  is  evident  that  the  rectum  did  not 
break  down  until  four  days  after  the  operation,  as  previous  to  that  time 
he  had  had  numerous  bowel  movements  without  escape  of  either  gas  or 
feces  through  the  wound.  Whether  the  necrosis  was  due  to  the  enema  or 
the  rectal  tube  or  straining  at  stool,  or  to  the  unprotected  condition  of 
the  rectum,  owing  to  the  levators  not  being  drawn  together  over  it,  it  is 
Impossible  to  say,  but  a  tear  was  probably  not  made  at  the  operation. 

Operation,  July  2,  1904- — Ether.  Separate  closure  of  rectal  and  urethral 
openings.  Incisions  were  made  in  the  previous  wound  and  the  fistulae  ex- 
cised. The  rectum  communicated  with  the  wound  by  two  fistulous  open- 
ings, first  close  to  the  anus  where  the  opening  would  admit  a  finger  tip, 
and  second  5  cm.  up  where  it  also  communicated  with  the  posterior  ure- 
thra. These  openings  were  joined  and  after  excision  of  the  edges  closed 
with  interrupted  fine  silk  sutures,  reinforcing  sutures  to  cover  in  the  first 
row  were  carefully  placed,  bringing  together  considerable  amount  of 
muscle  in  the  line  of  suture.  A  urethrotomy  wound  was  made  in  the  bul- 
bous urethra  and  a  catheter  inserted  through  it  into  the  bladder.  It  was 
found  impracticable  to  close  the  urethral  fistula.  After  packing  the  wound 
lightly  the  skin  was  approximated  on  each  side  with  catgut. 

Convalescence. — July  9.  Since  operation  the  patient  has  had  a  great 
deal  of  pain,  requiring  removal  of  retention  catheter  last  night.  The 
gauze  was  removed  on  the  third  day.  Last  night  feces  came  through  the 
perineal  wound  as  freely  as  before  operation. 

July  13,  1904- — The  catheter  has  been  replaced  with  the  hope  of  getting 
the  rectal  fistula  to  close. 

July  28,  1904- — Although  causing  considerable  pain  the  catheter  was  re- 
tained until  last  night.  The  rectal  opening  is  smaller,  but  liquid  stools 
still  escape  through  it. 

August  15,  1904- — 'The  patient  is  discharged.  He  now  voids  urine  at  in- 
tervals of  four  hours  without  pain  and  in  a  large  stream.  Often  all  of 
the'  urine  comes  through  the  meatus,  at  times  there  is  an  escape  of  urine 
into  the  rectum,  and  only  a  few  drops  come  through  the  perineal  fistula. 
Fecal  matter  does  not  come  through  the  urethra  or  through  the  perineal 
fistula,  but  gas  occasionally  passes  through  both. 

Examination. — A  silver  catheter  passes  into  the  bladder  with  ease.  There 
is  no  residual  urine  present.  The  vesical  tonicity  is  good,  but  the  bladder 
is  somewhat  contracted.  Rectal  examination  shows  a  small  opening  in  the 
anterior  wall.  The  patient  is  instructed  to  use  the  catheter  with  the  hope 
that  the  fistula  will  heal. 

December  7,  1904- — The  patient's  health  has  improved  greatly.  He  re- 
tains his  urine  for  five  or  six  hours,  and  voids  almost  entirely  through 
the  penis.  The  recto-urethral  fistula  has  not  closed  and  when  his  bowels 
are  loose  a  small  amount  of  feces  still  escapes.  He  has  had  frequent  re- 
currences of  painful  epididymitis  on  both  sides. 


232  Hugh  H.  Young. 

Third  operation,  February  6,  1905. — By  Drs.  Pitts  and  Smith,  of  Provi- 
dence, R.  I.  Perineal  incision,  exposure  of  rectal  fistula,  suture  of  edges; 
drainage  of  bladder  by  means  of  a  catheter.  Urethral  fistula  not  closed. 
The  catheter  remained  in  place  for  several  days.  The  patient  was  up  on 
the  16th  day,  and  left  the  hospital  on  the  19th.  Examination  at  end  of 
fourth  week  showed  complete  closure  of  the  rectal  wound,  slight  leakage 
of  the  perineal  fistula.  Bladder  holds  12  ounces  and  the  patient  does  not 
urinate  for  five  or  six  hours. 

Noveml)er  12,  1905. — The  patient  voids  urine  without  hesitation  or  difii- 
culty,  has  frequent  erections  and  feels  perfectly  well.  Examination  shows 
that  the  rectal  wound  is  healed  and  the  perineal  fistula  closed.  Epididy- 
mes  indurated  but  painless.  The  urine  is  almost  clear.  Micturition  nor- 
mal.    No  residual  urine. 

May  8,  1906. — Letter.  I  void  urine  naturally,  at  intervals  of  about  four 
hours,  often  16  ounces  at  a  time.  I  suffer  pain  in  the  scrotum.  Do  not 
have  erections  or  intercourse.  There  is  still  a  very  small  fistula  in  the 
perineum  through  which  a  few  drops  of  urine  escape.  I  am  entirely  cured 
of  the  obstruction  to  urination. 

May  19,  1906. — The  patient  returns  for  examination.  In  addition  to 
above  note  he  says  that  if  he  retains  urine  longer  than  four  hours  there 
is  occasionally  a  slight  escape  of  a  very  small  amount  of  urine,  perhaps  a 
teaspoonful,  but  this  is  easily  avoided  by  voiding  urine  at  intervals  of  less 
than  four  hours.     There  is  no  nocturnal  incontinence. 

Examination. — The  perineal  prostatectomy  wound  and  the  rectal  wound 
are  both  firmly  closed,  and  there  is  no  evidence  of  prostatic  enlargement 
present.  A  pin-point  fistula  at  the  site  of  the  bulbous  urethrotomy  wound 
persists.  A  silver  catheter  passes  with  ease.  There  is  no  residual  urine 
present,  and  the  bladder  capacity  is  400  cc.  There  is  no  stricture  present 
Urine  is  acid  and  contains  only  a  few  pus  cells.  The  fistula  in  the  bulbous 
urethra  was  almost  completely  excised,  and  no  sutures  introduced. 

Pathological  report. — The  specimen,  G.  U.  84,  consists  of  the  three  lobes 
of  the  prostate  each  in  one  piece  and  weighs  in  all  7  gm.  The  right  lobe 
is  the  largest;  it  is  fairly  smooth,  and  firm  in  consistence.  On  section  it 
is  pale  with  small  white  dots  in  a  grayish  stroma,  and  is  fibrous  in  feel. 
It  measures  2  x  1.7  x  1.3  cm.  The  left  lateral  lobe  is  somewhat  smaller 
and  is  similar  in  character  to  the  right.  The  median  lobe  has  been  torn 
into  three  pieces,  to  one  of  which  a  small  bit  of  mucous  membrane  has 
been  attached.  One  small  lobule  about  7  mm.  in  diameter  represents  most 
of  the  lobe.    No  ejaculatory  ducts,  no  calculi  removed. 

Microscopic  examination. — The  prostate  is  very  interesting  microscop- 
ically in  that  there  is  a  very  insignificant  amount  of  gland  tissue  present. 
The  acini  present  are  grouped  in  a  few  small  areas.  The 
stroma  contains  considerably  more  muscle  than  connective  tissue, 
the  muscle  fibers  being  often  grouped  together  in  bundles  sur- 
rounded by  a  small  band  of  connective  tissue  with  small  strands 
interlacing  between  the  muscle  fibers.  The  blood  vessels  do  not  seem 
to   show   any   particular   amount   of  arteriosclerotic   changes.     On   gross 


study  of  145  Cases  of  'Perineal  Prostatectomy.  233 

appearance  this  prostate  presented  none  of  the  typical  appearance 
of  benign  hypertrophy,  and  microscopically  there  is  no  accumulation 
of  gland  tissue  in  lobules.  Here  and  there  one  finds  an  area  where  there 
are  rather  numerous  acini  present  which  are  somewhat  dilated  and  present 
the  intraacinous  proliferation  which  one  sees  in  ordinary  hypertrophy 
cases.  The  median  portion  consists  largely  of  fibrous  tissue  apparently  of 
inflammatory  origin.  Numerous  areas  of  prostatitis  are  also  noted  in  the 
lateral  lobes. 

Case  40. — Moderate  enlargement  of  median  and  lateral  lobes.  Frequency 
and  difficulty  of  urination.     Occasional  hematuria.     Cured. 

No.  612.    R.  W.,  age  68,  single,  admitted  April  28,  1904. 

Complaint. — 1"  Frequency  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  about  four  years  ago  with  difliculty  of  urination. 
Since  then  there  has  been  a  slight  increase  in  this  trouble  and  a  little 
burning  at  the  neck  of  the  bladder.  Two  weeks  ago  hematuria  occurred, 
and  the  patient  consulted  a  physician  who  advised  prostatectomy. 

S.  P. — Urination  five  or  six  times  during  'the  day  and  four  times  at 
night.  No  pain,  but  a  slight  burning  during  urination.  Micturition  slow, 
at  times  very  difficult. 

Sexual  powers. — (Erections  are  still  present,  has  not  had  intercourse  for 
years. 

Examination. — Patient  is  well  nourished  and  his  lips  are  of  good  color. 
The  lungs  are  negative.  There  is  a  moderately  intense  systolic  murmur 
at  the  apex  and  the  area  of  cardiac  dullness  is  increased.  Sounds  at  the 
base  are  clear.    The  abdomen  and  genitalia  are  negative. 

Rectal. — The  prostate  is  moderately  hypertrophied,  being  about  the  size 
of  a  small  orange.  It  is  smooth,  soft,  elastic,  there  are  no  nodules,  the 
median  furrow  and  notch  are  obliterated.  The  seminal  vesicles  are  nega- 
tive. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1017,  no  sugar,  a  trace  of  albumin, 
urea  19  grams  per  liter.     Microscopically,  pus  cells  and  bacilli. 

Cystoscopic  examination.— A.  catheter  passes  with  ease  and  finds  75  cc. 
residual  urine.  The  bladder  capacity  is  diminished.  The  tonicity  is  ex- 
cellent. The  cystoscope  shows  a  fairly  large  left  lateral  lobe,  a  lesser 
right  lateral  lobe  with  a  deep  sulcus  between  them,  a  moderate  sized  me- 
dian lobe  with  a  deep  sulcus  between  it  and  the  left  lateral  lobe  and  a 
shallow  sulcus  between  it  and  the  right  lateral  lobe.  The  bladder  is 
trabeculated.  There  is  a  cystitis  of  moderate  degree,  no  calculus.  With 
finger  in  rectum  and  cystoscope  in  urethra,  the  beak  can  be  easily  felt, 
the  median  portion  of  the  prostate  being  moderately  increased. 

June  2,  1904. — Patient  returns  for  operation.  He  has  taken  urotropin 
once  daily  and  water  in  abundance.  He  has  had  no  pain.  Now  voids 
urine  about  every  two  hours  during  the  day  and  every  three  hours 
at  night.    His  general  health  is  excellent. 


234  Bugh  H.  Young. 

June  3,  190Jf. — Operation.  Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  easily  enucleated,  but  in  removing  the 
left  lateral,  which  was  the  larger,  a  tear  was  made  in  the  vesical  mucous 
membrane  covering  its  deeper  portion.  The  median  bar  was  removed,  a 
part  with  each  lateral  lobe.  The  tractor  being  withdrawn,  a  finger  intro- 
duced through  the  urethra  into  the  bladder  showed  a  small  median  ridge 
which  was  very  firmly  adherent  and  less  than  1  cm.  high.  It  seemed  un- 
necessary to  remove  this  and  nothing  else  was  removed.  The  wound  was 
closed  as  usual  with  double  tube  drainage  and  light  packs  for  the  lateral 
cavities.  The  patient  stood  the  operation  well,  his  pulse  being  90  at  the 
end.  On  return  to  ward  an  infusion  and  continuous  irrigation  were 
started. 

Convalescence. — The  patient  reacted  well.  Temperature  101°  on  the 
night  after  the  operation,  normal  again  after  five  days.  The  gauze  was 
removed  on  the  second  day,  and  tEe  drainage  tubes  on  the  fourth  day. 
He  began  to  walk  on  the  sixth  day,  urine  passed  through  the  anterior 
urethra  on  the  eighth  day,  and  the  fistula  closed  completely  on  the  twelfth 
day.  Control  was  established  soon  after  removal  of  the  tubes,  and  on  the 
eighth  day  the  patient  was  able  to  hold  urine  for  several  hours.  He  was 
discharged  on  the  19th  day,  the  wound  closed,  able  to  hold  urine  all  night, 
no  dribbling,  general  condition  excellent. 

October  1,  1904- — The  patient  has  been  treated  by  irrigations  with  the 
hope  of  curing  the  bacilluria,  but  without  success.  He  can  hold  urine  for 
six  hours  with  comfort.  The  catheter  meets  no  obstruction  and  finds  no 
residual  urine.  The  bladder  capacity  is  500  cc.  The  cystoscope  shows  a 
small  bar  in  the  median  portion  (which  was  intentionally  not  removed  at 
operation),  but  this  seems  to  cause  no  obstruction. 

February  1.  1905. — Letter.  I  am  entirely  cured.  I  void  urine  from  three 
to  five  times  during  the  day  and  once  or  twice  at  night,  large  amounts  at 
a  time.    I  have  no  pain.    Erections  have  not  returned. 

July  26,  1905. — 'Urine  is  retained  from  four  to  six  hours  during  the  day. 
Stream  large  and  free,  control  perfect.  Had  one  erection  two  months 
ago.    Urine  still  contains  bacilli. 

Pathological  report. — The  specimen,  G.  U.  85,  consists  of  the  two  lateral 
lobes  of  the  prostate,  each  removed  in  one  piece  and  weighs  in  all  43  gm. 
The  left  lateral  lobe  weighs  25  gm.,  measures  4x3x3  cm.;  presents  a  fairly 
smooth  external  surface  with  well  pronounced  capsule,  and  on  section 
numerous  spheroids  with  considerable  stroma  and  few  dilated  ducts.  The 
right  lobe  measures  3.5  x  3  x  2.3  cm.  and  weighs  18  gm.  It  is  similar  in 
character  to  the  left.  No  mucous  membrane,  no  ejaculatory  ducts,  no 
calculi. 

Microscopic  examination. — The  hypertrophy  in  both  lateral  lobes  pre- 
sents the  usual  picture  of  glandular  hypertrophy.  The  acini  are  quite 
dilated  with  complex  lumina  due  to  small  inshoots  in  the  periphery. 
These  inshoots  at  first  contained  a  thin  septum  of  connective  tissue  form- 
ing a  framework  for  the  epithelium  of  which  they  are  lined,  and  later  on. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  235 

as  the  septum  increases  in  thickness,  smooth  muscle  fibers  are  seen  to  be 
present.  In  areas  there  is  rather  marked  cystic  dilatation  with  flattening 
of  the  lining  epithelium.  The  stroma  seems  to  contain  more  glandular 
elements  than  muscular  fibers.  The  adenomatous  tissue  sems  to  be  ar- 
ranged largely  in  lobules.  Few  small  areas  of  interstitial  inflammatory 
infiltration  are  seen. 

Case  41. — Moderate  hypertrophy  of  median  and  lateral  lohes.  Catheter- 
ism.    Cured.    Followed  22  months. 

No.  694.     F.  J.  D.,  age  75,  married,  admitted  June  28,  1904. 

Complaint. — "  Enlarged  prostate.     Suprapubic  fistula." 

The  patient  had  never  had  gonorrhoea. 

Present  illness  began  14  years  ago  when  he  began  to  have  slight  diffi- 
culty in  micturition  which  gradually  increased.  About  four  years  ago  he 
consulted  a  doctor  who  told  him  that  he  had  an  enlarged  prostate  and  at- 
tempted to  pass  a  catheter  but  without  success.  Three  months  ago  mic- 
turition was  very  frequent  and  difiicult,  and  he  was  catheterized  for  the 
first  time,  and  a  large  amount  of  urine  withdrawn.  After  that  he  was 
catheterized  once  a  day  by  his  physician.  One  month  ago  he  had  an  at- 
tack of  severe  pain  in  the  region  of  the  right  kidney  which  lasted  several 
hours  and  returned  a  week  later.  During  the  past  two  weeks  he  has  suf- 
fered considerably  with  pain  in  the  bladder  and  has  been  catheterized 
twice  a  day. 

Status  prcesens. — The  patient  is  now  catheterized  three  times  daily, 
about  500  cc.  being  withdrawn  each  time.  About  five  hours  later  he  be- 
gins to  void  and  suffers  considerable  pain  until  he  is  relieved  by  catheter. 
He  says  that  he  occasionally  has  erections,  but  that  he  has  not  had  sexual 
desire  or  intercourse  for  several  years. 

Examination. — The  patient  is  a  well  nourished  man.  Lips  of  good 
color,  heart  and  lungs  negative.  No  tenderness  in  the  region  of  the  kid- 
neys. 

On  rectal  examination  the  prostate  is  found  to  be  moderately  and  sym- 
metrically enlarged,  round,  smooth  and  fairly  soft;  seminal  vesicles  not 
indurated.  The  urine  is  slightly  cloudy,  sp.  gr.  1010,  acid,  no  sugar,  al- 
bumin a  slight  trace.  Microscopically,  pus  and  bacteria.  Urea  27  grams 
daily. 

Preliminary  treatment. — Catheterization  three  times  a  day,  urotropin 
and  water  in  large  amounts  by  mouth.  Total  daily  amount  of  urine 
2500  cc. 

Operation,  July  2,  1904- — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  of  moderate  size  and  the  median  lobe 
quite  small.  In  removing  the  latter  a  small  tear  was  made  in  the  urethra. 
The  wound  was  closed  as  usual  with  gauze  packing  in  the  lateral  cavities 
and  double  drainage  tube  in  the  bladder.  The  patient  was  infused  on  the 
table,  and  his  condition  was  good  at  the  end  of  the  operation.  Pulse  at 
end   80. 


336  Hugh  H.  Young. 

Convalescence. — The  patient  reacted  well  and  continuous  irrigation  was 
kept  up  for  24  hours  when  the  gauze  was  removed.  The  catheters  were 
removed  on  the  next  day.  Urine  began  to  flow  through  the  penis  on  the 
sixth  day,  and  the  perineal  fistula  closed  on  the  tenth  day.  The  patient 
was  out  of  bed  on  the  fourth  day  and  began  to  walk  during  the  second 
week.  Highest  temperature  100.6°  on  the  second  day  after  the  operation, 
after  that  normal. 

July  26,  WO'f. — The  patient  can  hold  his  urine  for  five  hours.  Catheter 
passes  easily,  shows  no  evidence  of  stricture  and  finds  40  cc.  residual 
urine.  Bladder  capacity  is  300  cc.  Urine  is  voided  in  a  large  stream,  is 
clear,  acid,  contains  a  few  leucocytes  and  no  bacteria.  The  patient  dis- 
charged, 24th  day. 

October  23,  190^. — Letter.  I  am  a  well  man.  I  urinate  once  during  the 
night  and  every  six  hours  during  the  day.  I  have  no  incontinence,  but  if 
I  do  not  promptly  answer  the  call  there  may  be  a  slight  escape  of  urine, 
but  this  is  improving.     1  have  regained  my  normal  weight. 

February  1,  1905. — Letter.  I  void  urine  three  times  during  the  day  and 
once  at  night,  about  250  cc.  at  a  time,  with  a  large  stream  and  without 
pain.    I  have  occasional  erections. 

November  30,  1905. — Letter.  The  wound  has  remained  closed.  I  void 
urine  naturally  three  times  during  the  day  and  once  at  night,  about  one- 
half  pint  at  a  time.  I  suffer  no  pain,  erections  have  returned  and  my  gen- 
eral health  is  excellent,  and  I  think  I  am  cured. 

May  8,  1906. — Letter.  I  void  urine  naturally  four  times  during  the  day 
and  once  at  night.  I  have  no  pain.  Erections  have  returned.  I  have  had 
no  complications,  my  general  health  is  very  good.  I  have  gained  in  weight 
and  consider  myself  cured. 

Case  42. — Moderate  enlargement  of  median  and  lateral  lobes.  Catheter 
life.  Perineal  prostatectomy :  Incomplete  operation;  return  of  obstruction. 
Second  perineal  prostatectomy,  tear  into  rectum,  suture.  Result:  Recto- 
urethral  fistula.  Complete  relief  of  urinary  obstruction.  Little  discom- 
fort. 

No.  669.    J.  J.  P.,  age  63,  married,  admitted  July  14,  1904. 

Complaint. — "  Enlarged  prostate.    Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  about  seven  years  ago  with  difficulty  and  frequency 
of  urination  and  pain  along  the  urethra.  A  year  later  he  was  catheterized 
and  a  large  amount  of  residual  urine  discovered.  Three  years  ago  com- 
plete retention  of  urine  came  on,  and  since  then  he  has  catheterized  him- 
self three  times  a  day. 

S.  P.-^The  patient  is  unable  to  void  and  catheterizes  himself  four  times 
a  day.  Of  late  he  has  suffered  considerably  from  pain  in  the  prostate  and 
bladder.  He  has  not  lost  weight,  his  general  health  is  good.  His  sexual 
powers  are  normal. 

Examination. — ^The  patient  is  a  healthy  looking  man  with  lips  of  good 
color.  There  is  no  arteriosclerosis.  Heart,  lungs  and  abdomen  are  nega- 
tive. 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  237 

Rectal  examination. — The  prostate  is  slightly  enlarged  in  both  lateral 
lobes.  The  contour  is  irregular,  but  the  consistence  is  soft.  The  seminal 
vesicles  could  not  be  reached. 

Urinalysis. — Cloudy,  slightly  acid,  sp.  gr.  1016,  no  sugar,  no  albumin. 
Microscopically,  a  few  pus  cells  and  bacilli. 

Cystoscopic  examination. — A  large  coude  catheter  passes  with  ease  and 
finds  300  cc.  urine  present  (retention  of  urine  is  complete).  The  bladder 
is  large  and  the  tonicity  is  good.  The  cystoscope  shows  only  slight  intra- 
vesical hypertrophy  of  the  two  lateral  lobes,  and  a  small  rounded  median 
lobe  with  a  deep  sulcus  on  both  sides.  The  bladder  is  markedly  trabecu- 
lated  and  inflamed,  numerous  septa  and  deep  pouches  being  present. 
There  are  no  calculi  and  no  diverticula.  With  finger  in  rectum  and  cysto- 
scope in  urethra  the  median  portion  of  the  prostate  is  moderately  in- 
creased. 

Operation,  July  15,  1904. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  slightly  enlarged  and  were  very 
adherent  and  each  was  removed  in  two  pieces.  It  was  impossibe  to  en- 
gage the  median  lobe  with  the  tractor  which  was  then  withdrawn  and 
the  finger  inserted.  A  small  sessile  median  lobe,  the  size  of  a  pea,  was 
discovered  and  carried  into  the  left  lateral  cavity  by  means  of  the  index 
finger  of  the  left  hand  where  it  was  enucleated  by  means  of  a  sharp  peri- 
ostal  elevator,  a  small  tear  being  made  in  the  mucous  membrane  covering 
it.  After  removal  it  measured  1  cm.  in  diameter.  The  ejaculatory  ducts 
and  urethra  were  preserved  intact.  The  wound  was  closed  as  usual  with 
double  drainage  tubes  and  light  packs  for  the  lateral  cavities.  The  pa- 
tient's condition  at  the  end  of  the  operation  was  good.  Submammary  in- 
fusion was  given  on  return  to  ward  and  continuous  vesical  irrigation  was 
instituted. 

Convalescence. — The  patient  reacted  well,  but  had  a  slight  temperature 
for  five  days  after  the  operation,  reaching  101.7°  on  the  second  day.  The 
gauze  was  removed  at  the  end  of  30  hours,  and  the'  tubes  on  the  next  day. 
The  urine  began  to  pass  through  the  urethra  on  the  12th  day.  Epididy- 
mitis developed  on  the  left  side  on  the  18th  day,  and  was  accompanied  by 
fever  which  reached  104°  and  persisted  for  a  week.  On  August  5  phlebitis 
of  the  right  saphenous  vein  developed.  The  patient  left  the  hospital  Aug- 
ust 14.     The  perineal  fistula  was  not  healed,  and  urine  very  purulent. 

October  8,  1904. — The  patient  has  had  a  very  unsatisfactory  convales- 
cence. Both  testicles  have  suppurated  and  had  to  be  opened.  He  has  had 
considerable  trouble  from  phlebitis  and  the  fistula  has  never  healed.  He 
voids  urine  in  a  fairly  large  stream,  but  has  to  arise  three  times  during 
the  night,  and  a  catheter  finds  500  cc.  residual  urine.  Examination  of  the 
prostate  by  rectum  shows  a  fairly  considerable  cicatrix,  but  no  evidence 
of  remaining  prostatic  lobes.  The  cystoscope  shows  a  very  small  but 
rounded  median  bar,  the  lateral  lobes  are  not  at  all  enlarged. 

July  15,  1905. — From  January  until  May  the  patient  felt  well,  used  a 
catheter  at  bed  time  and  did  not  have  to  void  during  the  night.    Residual 


238  Eugli  H.  Young. 

urine  varied  from  50  to  500  cc.  During  the  day  he  voided  at  intervals  of 
two  hours.  About  one  month  ago  catheterization  bebcame  very  difficult 
and  painful.  For  the  past  V^o  Tveeks  he  has  had  to  use  the  catheter  three 
times  a  day  to  prevent  incontinence.  Cystoscopic  examination  again 
showed  a  small  rounded  median  mass  which  evidently  acted  as  an  ob- 
struction. With  finger  in  rectum  and  cystoscope  in  urethra,  a  hard  ring 
surrounding  the  cystoscope  was  found  in  the  region  of  the  prostate. 

The  following  remark  was  made:  It  was  evident  that  the  first  opera- 
tion did  not  completely  remove  the  enlargement  of  the  median  portion  of 
the  prostate  and  that  there  is  definite  obstruction  in  this  region  of  a  sub- 
urethral rather  than  an  intravesical  character.  A  second  perineal  opera- 
tion is  advised  with  the  object  of  removing  this  portion  of  the  prostate. 

July  11,  1905. — Operation.  Ether.  Inverted  V-incision  through  the 
scar  of  previous  operation.  The  prostate  was  very  difficult  to  expose,  ow- 
ing to  the  considerable  amount  of  cicatricial  tissue  and  its  intimate  adhe- 
sions to  the  rectum.  In  this  dissection  a  small  tear  was  made  by  the 
finger  in  the  rectum.  This  was  closed  apparently  satisfactorily  with  three 
layers  of  silk  sutures.  The  urethra  was  opened  through  the  left  lateral 
wall  and  the  median  portion  of  the  prostate  with  some  mucous  mem- 
brane was  removed.  This  measured  only  1x1x2  cm.  in  size,  but  very 
fibrous  and  had  to  be  excised  with  knife  and  scissors.  A  mass  of  tissue 
measuring  2  x  1%  x  1%  cm.  in  size  was  removed  from  the  left  lateral 
lobe.  The  region  of  the  right  lateral  lobe  was  not  removed.  The  rectum 
was  covered  over  with  the  levator  and  muscles  which  were  drawn  to- 
gether with  catgut  sutures.  The  wound  was  closed  as  usual  with  double 
tube  drainage  and  light  iodoform  gauze  packing. 

Convalescence. — The  patient  reacted  well,  but  had  a  slight  fever  for 
four  days.  The  gauze  was  removed  on  the  ninth  day  and  the  tubes  on  the 
tenth  day. 

July  30. — The  patient  is  up  in  a  wheel-chair.  Urine  has  passed  partly 
through  the  penis  since  the  seventh  day.  No  evidence  of  rectal  suture 
breaking  down. 

August  1. — Bowels  moved  for  the  first  time  to-day.  No  evidence  of 
rectal  suture  giving  way. 

August  5. — 'Bowels  moving  without  pain.  Urine  passes  through  the 
wound. 

August  8. — Fecal  matter  passed  through  the  penis  with  urine  to-day. 
Recto-urethral  fistula  present. 

August  16. — 'No  more  fecal  matter  through  the  penis,  but  flatus  escapes 
through  it.  Rectal  examination  discloses  a  small  opening  in  the  bowel, 
surrounded  by  considerable  tissue.  The  perineal  wound  is  healed  except 
for  a  pin-point  sinus.  The  patient  voids  urine  at  intervals  of  three  to 
five  hours  and  most  of  the  urine  comes  through  the  penis. 

August  20. — Rectal  and  perineal  fistula  persist.  The  patient  has  an  oc- 
casional severe  pain  in  the  urethra.    He  is  discharged  to-day. 


study  of  lJf-5  Cases  of  •Perineal  Prostatectomy.  239 

October  11,  1905. — Letter.  I  pass  urine  three  times  during  the  night 
and  in  the  morning  have  a  discharge  of  feces  and  urine  from  the  rectum, 
and  urine  coming  from  the  penis  twice  before  breakfast  and  generally 
two  or  three  times  after  breakfast.  After  the  middle  of  the  day  the  dis- 
charges are  less  frequent  and  more  controllable.  The  passage  of  fecal 
matter  through  the  penis  is  growing  less.  I  have  pain  before,  during  and 
after  the  discharges,  and  constant  soreness  in  perineum  and  testicles. 

December  17,  1905. — Letter.  The  perineal  fistula  is  closed  (Nov.  1).  I 
void  urine  naturally  about  ten  times  during  the  day  and  four  or  five  times 
during  the  night,  four  ounces  at  a  time.  I  suffer  pain  before,  during  and 
after  urination.     I  do  not  have  erections.    My  general  health  is  fair. 

February  6,  1906. — 'Letter.  The  perineal  wound  is  closed,  but  there  is 
still  a  communication  through  the  perineum  and  urethra  through  which 
gas  occasionally  escapes  into  the  urethra.  About  one-quarter  of  the  urine 
passes  through  the  rectum,  the  rest  is  voided  through  the  meatus.  I  uri- 
nate seven  times  during  the  day  and  four  times  at  night,  from  two  to  four 
ounces  at  a  time.  I  suffer  much  pain  before,  during  and  after  urination, 
but  am  comfortable  when  sitting  still. 

April  21,  1906. — The  recto-urethral  fistula  is  still  open,  but  no  feces  ever 
pass  through  the  penis,  and  when  the  bowels  are  very  loose  there  is  only 
a  very  slight  coloring  of  the  urine.  Frequently  no  urine  passes  into  the 
rectum,  but  if  he  strains  very  hard  (which  he  is  in  the  habit  of  doing  if 
the  urine  does  not  flow  at  once)  a  small  portion  of  urine  passes  into  the 
bowel,  but  this  occurs  very  rarely.  He  voids  urine  in  a  good  stream,  with- 
out difficulty,  and  at  intervals  of  about  six  hours  during  the  day.  He  often 
does  not  get  up  at  all  during  the  night  to  urinate.  He  has  practically  no 
pain,  only  a  slight  one  when  the  bladder  is  very  full.  He  looks  well  and 
has  gained  in  weight. 

Examination. — Patient  voided  150  cc.  of  slightly  cloudy,  acid  urine. 
With  the  finger  in  the  rectum  a  small  fistulous  opening  is  felt  4  cm.  above 
the  anus.  There  is  no  urine  in  the  rectum,  although  the  patient  has  just 
voided. 

Remark. — The  patient  says  he  feels  so  comfortable,  has  so  little  trouble 
on  account  of  the  fistula  that  he  does  not  wish  to  have  an  operation  to 
close  it.  The  prostatic  obstruction  seems  to  be  completely  relieved  as  a 
result  of  the  second  operation. 

Case  43. — Considerable  enlargement  of  the  lateral  lobes.  Catheterized 
twice  daily.    Cured.    No  complications.    Followed  21  months. 

No.  689.     J.  S.  T.,  age  72,  widower,  admitted  August  5,  1904. 

Complaint. — "  Incomplete    retention    of   urine.     Catheter  ism." 

No  history  of  gonorrhoea. 

Present  illness  began  six  years  ago  with  intermittent  attacks  of  fre- 
quency of  urination.  About  four  years  ago  he  began  to  have  hemorrhages 
from  the  urethra  while  asleep  and  occasionally  during  urination.  These 
continued  at  intervals  of  three  or  four  months.     In  December,  1903,  he 


240  Hugh  E.  Young. 

began  to  suffer  for  the  first  time  with  diflficulty  and  pain  during  urination. 
A  catheter  drew  off  one  quart  of  residual  urine.  Since  then  the  patient 
has  been  catheterized  twice  daily,  but  retention  of  urine  has  never  been 
complete. 

S.  P. — The  patient  is  in  good  health,  suffers  no  pain,  is  catheterized 
night  and  morning.  After  about  eight  hours  he  begins  to  void  fre- 
quently and  with  difficulty.  The  residual  urine  is  usually  a  pint.  No 
note  as  to  sexual  powers. 

Examination. — The  patient  is  a  sturdy-looking  man,  lips  of  good  color. 
The  pulse  is  regular,  72  to  the  minute,  and  the  arteries  are  not  sclerotic. 
The  chest  and  abdomen  are  negative. 

Rectal. — The  prostate  is  considerably  enlarged,  the  left  lobe  being  the 
larger,  and  its  upper  end  difficult  to  reach.  The  prostate  is  rounded, 
smooth,  elastic,  there  are  no  nodules  or  areas  of  induration.  The  semi- 
nal vesicles  are  not  palpable. 

Cystoscopic  examination. — <A  large  coude  catheter  passes  with  ease 
and  finds  650  cc.  residual  urine.  Cystoscopy  was  unsatisfactory  owing 
to   hemorrhage. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1022,  no  sugar,  trace  of  albumin,  urea 
10  grams  to  the  liter.     Microscopically,  pus  cells  and  a  few  hyaline  casts. 

Operation,  August  9,  1904. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  of  the  prostate  were  easily  enu- 
cleated and  were  removed  each  in  one  piece.  The  left  lateral  lobe  was 
the  larger,  measuring  8x5x6  cm.  in  size.  The  right  lobe  measured 
about  6  cm.  in  diameter.  No  tear  was  made  in  the  urethra  or  bladder. 
An  attempt  was  made  to  examine  the  vesical  orifice  with  a  finger 
through  the  urethra,  but  owing  to  the  great  length  of  the  urethra  this 
was  impossible.  By  palpating  the  neck  of  the  bladder  against  the 
prostatic  tractor,  the  operator  concluded  that  there  was  little  if  any 
median  enlargement  and  nothing  further  was  removed.  The  wound 
was  closed  as  usual  with  double  catheter  drainage.  Light  packs  for 
the  lateral  cavities.  The  patient  stood  the  operation  well.  He  was  in- 
fused on  the  table  and  continuous  irrigation  begun  on  return  to  ward. 
His  pulse  at  the  end  of  the  operation  was   95. 

Convalescence. — ^The  temperature  on  the  day  following  the  operation 
reached  102°,  but  returned  to  normal  on  the  third  day.  After  that  there 
was  an  evening  temperature  of  100°  almost  every  day  until  August  20. 
The  gauze  and  catheters  were  removed  -m  the  third  day.  On  the  11th 
day  half  of  the  urine  came  through  the  urethra,  and  the  patient  was  able 
to  hold  his  urine  for  four  hours  and  was  up  and  about.  The  perineal 
fistula  closed  on  the  16th  day  and  the  patient  was  discharged  on  the 
17th  day.  At  that  time  he  had  perfect  control  and  retained  his  urine 
for  six  hours  or  more  and  the  wound  Nvas  closed.  His  condition  was 
excellent. 

February  1,  1905. — I  have  not  used  a  catheter  since  operation.  I  void 
urine  four  times  during  the  day  and  twice  at  night,  about  400  cc.  at  a 


study  of  145  Cases  of  •Perineal  Prostatectomy.  2-il 

time.  I  have  no  pain  and  consider  myself  cured.  I  have  no  erections. 
My  general  health  is  excellent. 

November  30,  1905. — Letter.  The  wound  remains  healed.  I  void 
urine  naturally,  once  at  night,  four  to  five  times  during  the  day,  about 
400  cc.  at  a  time.  I  have  a  slight  burning  in  the  urethra  after  urina- 
tion. I  have  no  erections.  My  general  health  is  excellent,  and  I  con- 
sider myself  cured. 

May  7,  1906. — ^Letter.  I  void  urine  naturally  about  four  times  a  day 
and  once  at  night,  from  300  to  400  cc.  at  a  time.  I  have  no  pain,  no 
erections.     My  general  health  is  good  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  91,  consists  of  the  two  lat- 
eral lobes  of  the  prostate,  each  of  which  has  been  removed  in  one  small 
piece,  and  weighs  in  all  78  gm.  The  left  lobe  is  a  large  oval  mass 
8x5x4  cm.  in  size  and  weighs  55  gm.  It  is  composed  of 
lobules  more  or  less  encapsulated  and  firmly  bound  together.  It  is 
elastic  on  section;  and  there  are  numerous  large  and  small  spheroids 
with  little  intervening  stroma,  and  few  dilated  acini.  The  right  lobe 
measures  5x4x2.5  cm.  and  weighs  23  gm.  It  is  more  lobulated  than 
the  left,  and  on  section  shows  more  dilated  acini,  but  there  is  very 
little  stroma.     No  mucous  membrane,  no  ejaculatory  ducts,  no  calculus. 

Microscopic  examination. — The  hypertrophy  is  a  markedly  glandular 
one,  and  shows  the  usual  arrangement  in  lobules.  The  acini  are  in  some 
areas  small,  in  others  moderately  dilated,  and  some  show  considerable 
cystic  degeneration  with  fiattening  of  the  lining  epithelial  cells.  There 
is  rather  an  extensive  prostatitis  present.  The  stroma  contains  much 
more  connective  tissue  than  muscle.  There  are  areas  where  the  epithe- 
lium lining  the  endoglandular  sprouts  shows  a  rather  wild  profusion. 
No  evidence  of  carcinoma. 

Case  44. — \SligM  enlargement  of  lateral  and  mecLian  lobes.  Residual 
urine  1000  cc.  Operation  incomplete.  Median  bar  left.  Improved.  Un- 
satisfactory result.     Followed  21  months. 

No.  1330.    F.  D.,  age  65,  married,  admitted  August  5,  1904. 

Complaint. — "  Inability  to  hold  urine." 

No   history   of  gonorrhoea. 

Present  illness  began  three  years  ago  with  increased  frequency  of 
urination.  Of  late  this  has  increased  considerably  and  urination  has 
been  very   precipitate. 

8.  P. — ^Urination  every  15  minutes  during  the  day  and  six  to  eight 
times  during  the  night.  No  pain,  no  straining  on  urination,  but  con- 
siderable precipitancy.  Has  never  had  complete  retention,  nor  has  been 
catheterized. 

Sexual  powers. — Normal  up  to  three  months  ago,  since  then  no  erec- 
tions.    General  health   good. 

Examination. — The  patient  is  a  rather  weak-looking  man  with  lips 
slightly  pale.  The  chest  wall  is  rigid,  percussion  hyperresonant 
throughout. 


342  Hugh  H.  Young. 

Heart. — 'The  point  of  maximum  impulse  is  in  the  fifth  interspace 
about  1  cm.  outside  of  the  nipple  line.  The  sounds  are  clear  at  apex 
and  base,  but  the  second  aortic  is  markedly  accentuated  and  the  first 
aortic  is  rumbling  in  character.     Abdomen  and  genitalia  negative. 

Rectal. — 'The  prostate  is  very  slightly  enlarged,  but  it  bulges  consid- 
erably more  towards  the  rectum  than  the  normal  prostate,  and  the 
median  groove  and  notch  are  replaced  by  a  rounded  mass.  It  is  smooth, 
rounded,  elastic,  and  uniform.  The  seminal  vesicles  are  soft,  and  there 
are  no  glands  to  be  felt. 

Cystoscopic.-^A.  large  coudS  catheter  is  obstructed  in  the  middle  of 
the  prostatic  urethra  and  will  not  enter  the  bladder.  A  silver  catheter 
is  passed  with  ease,  and  1000  cc.  residual  urine  withdrawn.  The  cys- 
toscope  shows  a  very  slight  hypertrophy  of  the  median  and  lateral 
lobes  in  the  shape  of  a  collar  v/ith  a  small  cleft  anteriorly.  The  me- 
dian portion  is  only  slightly  increased  in  the  shape  of  a  bar.  The  ure- 
ters and  most  of  the  trigone  are  seen.  With  finger  in  rectum  and  cys- 
toscope  in  urethra  there  is  only  slight  increase  in  the  median  portion 
of  the  prostate. 

Urinalysis. — The  urine  is  clear  and  contains  no  pus  or  bacteria.  Sp. 
gr.  1009,  acid,  no  sugar,  albumin  a  trace. 

Preliminary  treatment. — Urotropin,  water  in  abundance,  and  catheteriza- 
tion two  or  three  times  daily.  Under  this  treatment  the  patient  im- 
proved considerably,  but  he  voided  large  quantities  of  urine.  The  spe- 
cific gravity  increased  from  1009  to  1015,  and  the  urea  from  10  gm.  to 
14  gm.  per  liter. 

Operation,  August  18,  1904. — Chloroform.  Perineal  prostatectomy  by 
the  usual  technique.  The  lateral  lobes  were  easily  enucleated  each  in 
one  piece  and  were  only  slightly  enlarged.  A  small  rounded  median 
lobe,  the  size  of  a  filbert,  was  enucleated  from  beneath  the  urethra.  (At 
the  time  it  was  supposed  that  this  represented  all  the  median  enlarge- 
ment, and  nothing  further  was  removed.  The  finger  was  not  inserted 
through  the  urethra  into  the  bladder.)  The  wound  was  closed  as  usual 
with  double  tube  drainage  and  light  packs  for  the  lateral  cavities.  The 
patient  stood  the  operation  well,  pulse  at  the  end  70.  Continuous  irri- 
gation on  return  to  the  ward. 

Convalescence. — *The  temperature  did  not  rise  above  99.4°,  and  the 
patient  reacted  well.  Continuous  irrigation  was  stopped  at  the  end  of 
28  hours.  The  gauze  and  tubes  were  removed  on  the  third  day,  and  the 
patient  was  out  of  bed  on  the  fourth  day.  On  the  fifth  day  a  fair 
amount  of  urine  was  voided  through  the  penis,  and  the  patient  was 
discharged  on  the  25th  day.  The  perineal  fistula  was  still  open,  and 
there  was  a  slight  incontinence  of  urine.  His  general  condition  was 
excellent. 

March  25,  1905. — ^The  perineal  fistula  is  not  yet  closed,  and  the  patient 
voids  urine  at  frequent  intervals.  A  catheter  finds  sometimes  200  cc. 
and  at  others  300  cc.  residual  urine.  The  cystoscope  shows  a  slight 
round  median  bar,  but  no  sulcus  on  either  side,  and  a  small  intraure- 


study  of  lJf5  Cases  of  ■Perineal  Prostatectomy.  243 

thral  lobule  on  the  right  s5de  somewhat  anterior  to  the  cystoscope. 
With  finger  in  rectum  and  cystoscope  in  urethra  the  median  portion 
feels  no  thicker  than  normal.  The  patient  was  advised  to  catheterize 
himself  once  daily. 

September  6,  1905. — The  patient  catheterizes  himself  twice  a  day  and 
finds  about  300  cc.  residual  urine.  A  small  perineal  fistula  is  still  pres- 
ent through  which  only  a  few  drops  of  urine  escape.  The  cystoscope 
shows  a  small  rounded  median  lobe  which  has  grown  definitely  since 
the  last  examination,  six  months  ago.  There  is  also  a  slight  hyper- 
trophy of  both  lateral  lobes  which  present  mostly  intraurethrally,  but 
do  not  come  together  in  front.  The  bladder  is  moderately  inflamed. 
There   is  no  stone   present. 

Note. — It  seems  evident  that  the  median  portion  of  the  prostate  was 
not  completely  removed  at  operation  and  the  result  has  never  been  satis- 
factory. The  median  lobe  now  is  distinctly  larger  than  before  operation. 
Another  operation  was  advised,  but  the  patient  would  not  submit  to  it. 

May  19,  1906. — 'Patient  returns  for  examination.  He  says  he  uses  the 
catheter  at  night  and  withdraws  about  half  a  pint  of  urine.  He  then 
does  not  urinate  until  morning.  He  generally  uses  a  catheter  also  on 
arising  in  the  morning  and  about  four  hours  later  begins  to  void  urine 
naturally,  and  after  that  urinates  at  intervals  of  two  hours  until  cath- 
eterization at  bed  time.  He  would  be  able  to  get  along  without  cathe- 
terization, but  feels  more  comfortable  under  this  treatment.  A  few 
drops  of  urine  escape  through  the  fistula  at  each  urination.  There  is 
no  incontinence,  his  general  health  is  good.  He  does  not  have  erec- 
tions. 

Examination. — The  patient  looks  well.  He  voided  100  cc.  of  urine 
and  a  catheter  withdrew  400  cc.  The  cystoscope  shows  a  small  but  defi- 
nite rounded  median  lobe  with  a  very  shallow  sulcus  on  the  left  side. 
The  lateral  lobes  are  not  at  all  intravesically  enlarged.  There  is  no 
stone  present,  the  bladder  is  only  slightly  trabeculated  and  moderately 
inflamed. 

Remark. — ^It  is  evident  that  in  this  case  all  of  the  median  prostatic 
obstruction  was  not  removed,  and  the  imperfect  result  is  directly  due 
to   this   cause. 

Pathological  report. — 'The  specimen,  G.  U.  92,  consists  of  the  two  lat- 
eral lobes  of  the  prostate  and  weighs  15  gm.  The  left  lobe  has  been 
removed  in  one  piece,  weighs  9  gm.,  is  coarsely  lobulated,  and  consid- 
erably torn.  One  large  spheroid  about  2  cm.  in  diameter  is  present.  On 
section  there  is  considerable  stroma,  and  slight  amount  of  gland  dilatation. 
The  right  lobe  weighs  6  gm.,  is  also  irregular,  and  has  been  removed 
in  two  pieces.  On  section  it  is  very  firm,  there  is  considerable  stroma, 
no  gland  dilatation.  No  mucous  membrane  has  been  removed,  no  cal- 
culi.    No   ejaculatory  ducts   seen. 

Microscopic  examination. — The  hypertrophy  in  both  lobes  is  of  the  same 
character,  and  the  gland  tissue  and  stroma  are  present  in  about  equal 
amounts.     There  is  some  lobulation  present,  but  even  within  the  lobules 

Vol.  XIV.— 17. 


244  Hugh  H.  Young. 

the  stroma  is  almost  as  plentiful  as  the  gland  tissue.  The  acini  within 
the  lobules  are  separated  from  each  other  as  a  rule  by  fair  sized  bands  of 
interstitial  tissue.  The  acini  are  only  slightly  dilated,  and  in  many  places 
quite  small.  The  acini  in  the  stroma  about  the  periphery  are  compressed. 
The  acini  as  a  whole  do  not  show  the  same  tendency  to  proliferation  and 
complexity  of  lumina  which  one  sees  in  more  glandular  hypertrophy.  The 
stroma  contains  a  large  amount  of  muscle,  the  relative  amounts  of 
muscle  and  connective  tissue  varying  in  different  areas.  The  hyper- 
trophy is  one  in  which  there  has  been  an  increase  in  the  fibrous  and 
muscular  elements  in  fairly  equal  proportions. 

Case  45. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Four 
vesical  calculi.  Improvement.  Pain  still  present  (calculus  returned'?). 
Catheter  not  required. 

No.  703.     P.  A.  H.,  age  58,  married,  admitted  August  8,  1904 

Complaint. — '"  Bladder  trouble." 

No   history    of   gonorrhoea. 

Present  illness  began  six  years  ago  with  increased  frequency  of  uri- 
nation and  burning  in  the  urethra.  During  the  next  four  years  there 
was  a  gradual  increase  in  both  of  these  symptoms,  the  pain  being  se- 
vere. Complete  retention  of  urine  came  on  for  the  first  time  two  years 
ago  and  he  was  catheterized.  After  that  retention  and  catheterization  at 
gradually  shortening  intervals.  For  three  weeks  past  retention  has  been 
complete  and  the  catheter  necessary  every  four  to  six  hours.  Has  had  con- 
siderable pain  across  the  back  and  in  the  bladder,  but  none  elsewhere. 

g:.  p. — The  patient  is  now  able  to  pass  small  amounts  of  urine,  but  uses 
the  catheter  twice  daily.     He  has  not  lost  weight. 

Sexual  powers. — Erections  and  intercourse  were  normal  up  to  three 
months  ago.  During  the  past  year  there  has  been  a  slight  pain  on 
ejaculation   and   an   apparent   stoppage — 'very   little  semen. 

Examination. — (Patient  is  well  nourished  with  lips  of  good  color.  Chest 
and  abdomen   negative. 

Rectal. — -The  prostate  is  moderately  hypertrophied,  about  the  size  of 
a  small  apple.  It  is  round,  smooth,  firm  but  not  hard.  Median  furrow 
and   notch    are    obliterated.      The   seminal   vesicles   are   not  palpable. 

Cystoscopic. — The  patient  voided  150  cc.  and  a  coude  catheter  found 
65  cc.  residual  urine.  The  bladder  capacity  is  420  cc.  Urethral  length 
9%  inches.  The  cystoscope  shows  a  moderate  hypertrophy  of  the  lat- 
eral lobes  with  a  fairly  deep  cleft  between  them  in  front  and  an  irregu- 
lar granular  small  median  bar  w^hich  joins  them  posteriorly.  In  the 
base  of  the  bladder  are  several  stones  covered  by  considerable  mucous. 
The  bladder  is  infiamed.  With  finger  in  rectum  the  cystoscope  in  urethra 
there  is  considerable  increase  in  the  thickness  of  the  median  portion  of  the 
prostate,  but  very  little  in  the  urethral  length. 

Urinalysis. — Cloudy,  1012,  acid,  no  sugar,  albumin  a  trace.  Micro- 
scopically, pus  and  bacteria. 

Operation,  August  22,  190Jf. — Ether.  Perineal  prostatectomy  by  the 
usual   technique. 


study  of  145  Cases  of  'Perineal  Prostatectomy.  245 

Lithotomy. — 'Left  lateral  lobe  was  only  slightly  hyper trophied  and 
was  removed  in  two  pieces,  one  of  which  lay  anterior  to  the  urethra. 
The  right  lateral  lobe  was  moderately  enlarged,  and  a  small  median  bar 
was  removed  in  one  piece  with  it.  Examination  with  the  finger  in  the 
urethra  then  showed  no  remaining  prostatic  enlargement.  A  small  gall 
bladder  scoup  was  then  introduced  and  four  small  calculi,  6,  8  and  12 
mm.  in  diameter  were  removed.  The  urethra  was  torn,  but  no  mucous 
membrane  was  removed.  The  wound  was  closed  as  usual  with  double 
drainage  tubes  in  the  bladder  and  light  packs  for  the  lateral  cavities. 
Patient  stood  the  operation  well.  Pulse  at  the  end  95.  Infusion  and  con- 
tinuous irrigation  on  return  to  the  ward. 

Convalescence. — ^he  patient  reacted  well.  The  temperature  rose  on 
the  day  after  the  operation  to  100.4°,  but  was  normal  the  next  day 
and  only  once  rose  to  100°  afterwards.  Continuous  irrigation  was  kept 
up  for  48  hours  when  the  gauze  and  catheters  were  removed.  The  pa- 
tient was  out  of  bed  on  the  fourth  day,  condition  excellent.  On  the 
eighth  day  slight  epididymitis,  which  was  relieved  by  ice  cap.  Urine 
came  through  the  anterior  urethra  on  the  eighth  day,  and  the  perineal 
fistula  closed  on  the  18th  day.  The  patient  was  discharged  on  the  21st 
day  in  good  condition,  the  wound  healed,  voiding  urine  in  a  good  stream. 
A  silver  catheter  passed  easily,  and  showed  50  cc.  residual  urine  and  blad- 
der capacity  of  250  cc. 

November  30,  1905. — Letter.  The  wound  has  remained  healed,  and 
I  have  not  used  a  catheter.  During  the  night  I  am  able  to  sleep  four 
hours,  but  in  the  day  I  suffer  pain  and  void  urine  frequently,  some- 
times every  30  minutes.  I  have  a  feeling  as  if  a  gravel  is  trying  to 
pass.  I  am  very  nervous  and  have  lost  25  pounds  in  weight.  I  have 
no   desire  for   sexual   intercourse. 

Note.^lt  is  evident  that  calculus  is  present,  and  probably  responsible 
for  the  pain  and  frequency  of  urination  in  the  day  time. 

Pathological  report.-^The  specimen,  G.  U.  93,  consists  of  two  lateral 
lobes  removed  in  three  pieces.  There  is  no  median  lobe  present.  Total 
weight  of  the  prostate  is  22  gm.,  the  right  lobe  weighing  14  and  the  left 
8  gm.  The  right  lateral  lobe  is  coarsely  lobulated,  of  uniform  consist- 
ency, soft  and  elastic.  Its  constituent  spheroids  are  firmly  bound  to- 
gether by  connective  tissue.  The  left  lateral  lobe  has  been  removed  in 
two  pieces  which  are  similar  in  character  to  the  other  lobes.  No  evi- 
dence of  ejaculatory  ducts  or  urethral  mucous  membrane  is  present. 
Four  small  stones  have  been  removed.  These  have  a  smooth  surface,  and 
are  about  equal  in  size,  each  measuring  .5  cm.  in  diameter. 

Microscopic  examination. — 'The  hypertrophy  is  a  distinctly  glandular 
one  with  a  lobular  arrangement.  Within  the  lobules  the  acini  are 
rather  small,  closely  set  with  rather  slender  bands  of  interlacing  stroma. 
About  the  periphery  of  the  lobules  the  stroma  is  condensed,  and  con- 
tains numerous  elongated  flattened  culs-de-sac.  The  stroma  contains 
considerable  spindle-cell  tissue  especially  where  the  glandular  prolif- 
eration is  most  marked.  There  is  a  comparatively  small  amount  of 
muscle  in   the   stroma. 


246  Hugh  II.   Young. 

Case  46. — 'Moderate  hypertrophy.  Residuum  80  cc.  Bladder  con- 
tracted, 160  cc.  Result:  Relieved  of  difficulty,  pain  and  frequency  con- 
siderably.   Secondary  calculus  probable. 

No.  705.     W.  W.  H.,  age  68,  married,  admitted  August  20,  1904. 

Complaint. — ^'  Bladder  and  prostatic  trouble." 

No  history   of  gonorrhoea. 

Present  illness  began  four  years  ago  when  the  patient  had  two  hem- 
orrhages from  his  bladder.  Previous  to  that  there  had  been  no  diffi- 
culty or  frequency  of  urination.  Since  then  there  has  been  a  gradual 
incx'ease  in  the  frequency  and  difficulty  of  urination,  but  only  once  has 
there  been  any  blood  in  the  urine.  Pain  has  been  present  for  several 
months  and  is  worse  during  urination.  He  has  never  had  complete  re- 
tention of  urine  nor  has  he  been  catheterized. 

8.  P.— »The  patient  voids  urine  about  nine  times  at  night  and  every 
half  hour  during  the  day.  Urination  is  difficult  and  slow  and  painful, 
particularly  at  the  end  of  the  penis.  He  has  no  pain  in  the  back,  rec- 
tum or  thighs  and  his  urine  is  clear.  He  has  lost  30  pounds  in  the 
last  year.  One  week  ago  his  testicle  became  swollen,  but  subsided 
rapidly  under  applications  of  ice.  His  bowels  are  regular  and  defeca- 
tion not  painful.  His  chief  complaint  is  pain  which  is  very  severe. 
Erections  are  weak  and  intercourse  impossible. 

Examination. — 'The  patient  is  well  nourished  with  mucous  membranes 
of  good  color.  His  heart  and  lungs  are  negative.  His  pulse  70  to  the 
minute,   arteries   soft.      Abdomen   is   negative. 

Genitalia.— *TheTe  is  no  urethral  discharge.  The  right  epididymis 
and  vas  are  indurated.  Left  epididymis  is  also  indurated.  On  the  right 
side  there  is  a  small  complete  inguinal  hernia. 

Rectal  examination. — The  prostate  is  considerably  enlarged  in  both 
lateral  lobes,  the  upper  end  being  difficult  to  reach,  especially  on  the 
left  side.  The  median  furrow  is  shallow,  but  the  notch  is  quite  deep. 
The  prostate  is  soft,  elastic,  smooth  and  there  are  no  areas  of  indura- 
tion. On  the  left  side  the  prostate  extends  well  up  into  the  region  of 
the  seminal  vesicle,  but  there  is  no  induration  and  there  are  no  glands 
to    be    felt. 

Cystoscopic  exam,ination. — ^A  coude  catheter  passes  with  ease  and  finds 
80  cc.  residual  urine.  Bladder  capacity  is  160  cc,  the  tonicity  good. 
Urethral  length  is  nine  and  one-half  inches.  During  the  introduction 
of  the  cystoscope  traumatism  of  the  prostatic  urethra  was  produced, 
making  cystoscopy  very  unsatisfactory.  It  was  impossible  to  get  a 
good  view  of  the  bladder,  but  no  tumor  or  stone  was  seen.  The  base 
of  the  bladder  and  ureters  could  not  be  seen.  The  prostatic  orifice  was 
surrounded  by  considerable  hypertrophy  in  the  shape  of  a  collar,  but 
the  clefts  could  not  be  made  out.  With  finger  in  rectum  and  cystoscope 
in  urethra  it  was  impossible  to  feel  the  beak  of  the  instrument,  owing 
to  the  increased  length  of  the  prostate. 

Urinalysis. — Cloudy,  slightly  acid,  sp.  gr.  1012,  albumin  in  small  amount. 
Microscopically,  pus  and  bacilli  in  great  number. 


study  of  11^5  Cases  of  'Perineal  Prostatectomy.  247 

Operation,  August  26,  190^. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Unfortunately  no  careful  notes  of  this  operation  have 
been  preserved.  The  lobes  were  indurated,  very  adherent  and  came 
away  in  numerous  small  pieces.  The  median  portion  of  the  prostate 
was  small  and  was  removed  through  one  of  the  lateral  cavities.  No 
stone  was  found  in  the  bladder.  The  wound  was  closed  as  usual  with 
tube    and    gauze    drainage. 

Convalescence. — -The  patient  reacted  well,  his  pulse  being  88  at  the 
end  of  the  operation.  He  was  given  an  infusion  on  return  to  the  ward. 
The  gauze  and  tubes  were  removed  together  on  the  third  day,  and  the 
urine  first  passed  through  the  penis  on  the  ninth  day.  There  was  more 
hemorrhage  and  pain  than  usual  and  the  irrigation  was  continued  for 
two  days.  On  the  second  day  the  patient  began  to  be  nauseated  and  con- 
tinued so  until  the  sixth  day.  During  this  time  he  had  a  fever  which 
reached  103°  on  the  third  day.  The  patient  was  difficult  to  manage  and  in- 
sisted on  leaving  on  the  15th  day.  At  that  time  urine  was  still  coming 
through  the  perineum,  and  his  condition  was  not  comfortable.  (The 
operator  was  out  of  town  during  most  of  his  stay  in  the  hospital,  and 
did  not  see  him  when  he  left.) 

November  30,  1905. — Letter.  The  perineal  wound  is  closed.  I  do  not  use 
a  catheter,  but  void  urine  very  frequently,  sometimes  every  10  minutes. 
Very  seldom  does  one  hour  intervene  between  urinations  except  at  night. 
The  largest  amount  voided  is  about  two  and  one-half  ounces.  I  suffer 
pain,  before,  during  and  after  urination.  Erections  are  present,  but  weak. 
May  8,  1906. — 'Letter.  The  perineal  wound  has  remained  healed.  I 
am  not  cured,  I  void  urine  too  frequently  and  suffer  pain.  I  am  not 
very  much  better  than  1  was  several  months  ago.  I  think  my  trouble 
is  with  the  bladder  and  not  with  the  prostate  gland.  I  have  erections 
seldom  and  very  feeble,  too  imperfect  for  sexual  intercourse. 

Pathological  report. — 'The  specimen,  G.  U.  94,  consists  of  numerous 
pieces  which  go  to  form  the  right,  left  and  median  lobes  of  the  pros- 
tate which  weigh  respectively  12  gm.,  14  gm.,  4  gm.,  the  total  weight 
being  30  gm.  The  tissue  is  composed  of  many  small  spheroids  more  or 
less  firmly  attached  to  each  other.  The  consistence  is  soft  and  elastic, 
and  the  color  yellowish  gray.  No  mucous  membrane  or  ejaculatory  ducts 
have  been  removed. 

Microscopic  examination. — iThe  hypertrophy  is  a  moderately  glandu- 
lar one.  The  acini  are  dilated,  some  showing  flattening  of  the  epithe- 
lium and  cystic  degeneration.  The  acini  show  considerable  glandular 
proliferation.  Here  and  there  are  areas  of  fibrous  tissue  hyperplasia 
in  which  the  glands  are  undergoing  atrophy,  evidently  the  result  of  an 
old  prostatitis.  The  gland  tissue  is  for  the  most  part  arranged  in  lob- 
ules, the  peripheral  stroma  containing  compressed,  and  in  some  in- 
stances, atrophied  acini.  The  stroma  is  rather  dense,  and  contains  con- 
siderable young  connective  tissue.  The  muscle  element  is  compara- 
tively small  in  amount,  and  is  much  more  in  evidence  in  the  heavy 
bands  of  stroma.  Some  prostatitis  is  present.  The  arteries  are  normal 
except  in  some  fibrous  areas  where  they  are  considerably  thickened. 


248  Hugh  H.  Young. 

Case  47. — \SligTit  enlargement  of  prostate.  Large  oxalate  calculus. 
No   pain.     Cure.     Followed   20   months. 

No.  714.     J.  A.  S.,  age  65,  married,  admitted   September  2,  1904. 

Complaint. — "  Frequency  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  10  years  ago  with  slight  frequency  of  urina- 
tion during  the  day  and  burning  sensation  in  the  urethra  during  the 
night.  Four  years  ago  he  began  to  get  up  at  night  to  urinate,  and  has 
had  very  frequent  urination  during  the  day,  but  no  pain.  One  month 
ago  for  the  first  time  he  began  to  have  a  dull  soreness  in  the  urethra 
during  and  after  urination,  but  no  severe  pain  and  no  hemorrhage. 
These  symptoms  have  persisted  up  to  the  present  time. 

S.  P. — 'The  patient  voids  urine  every  hour  during  the  day,  but  with- 
out difficulty  or  pain.  There  is  a  slight  soreness  in  the  urethra  just 
before  and  after  urination  which  soon  disappears.  Sexual  powers  were 
normal  up  to   a   month   ago.     His  general  health  has  remained   good. 

Examination. — Patient  is  a  strong,  well  nourished  man  with  lips  of 
good  color.  Heart  and  lungs  are  negative.  Arteries  are  slightly  scle- 
rotic.    Chest  and   abdomen   negative. 

Rectal. — Prostate  is  moderately  enlarged  in  both  lateral  lobes, 
rounded  in  contour,  smooth,  firm  but  elastic  with  no  areas  of  indura- 
tion.    The   seminal   vesicles   are   not   indurated. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1020,  albumin  a  trace,  no  sugar,  urea 
10  gm.  daily.     Microscopically,  squamous  epithelium. 

Cystoscopic  examination. — ^A  catheter  passes  with  ease  and  finds  only 
15  cc.  residual  urine.  The  bladder  is  very  irritable  and  will  hold  only 
50  cc.  The  cystoscope  shows  a  large  rough  brown  stone  lying  between 
the  upper  limits  of  the  intravesical  portions  of  the  prostate  and  the 
anterior  wall  of  the  bladder.  There  is  no  stone  in  the  region  of  the 
trigone  or  base  of  the  bladder.  Study  of  the  prostatic  orifice  shows  a 
moderate  hypertrophy  of  both  lateral  lobes,  and  a  small  median  bar. 
With  finger  in  rectum  and  cystoscope  in  urethra  there  is  only  a  mod- 
erate  increase   in  the  median   portion. 

Operation,  September  3,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique,  and  lithotomy.  The  lateral  lobes  were  only  slightly 
hypertrophied  and  were  easily  removed.  Examination  showed  that  the 
enlargement  of  the  median  portion  was  too  small  to  warrant  removal. 
The  urethra,  which,  up  to  this  point,  was  not  torn,  was  now  divided 
with  scissors  along  its  left  lateral  surface,  the  neck  of  the  bladder  di- 
lated and  stone  forceps  inserted.  A  large  stone  was  at  once  caught 
and  drawn  towards  the  urethra.  It  was  found  to  be  too  large  to  come 
through  the  dilated  vesical  orifice.  By  making  stout  traction  upon  the 
forceps  the  vesical  neck  was  drawn  well  into  the  left  lateral  cavity  of 
the  prostate  where  it  was  easily  divided  with  a  scalpel  upon  the  stone 
which  was  at  once  extracted  through  the  enlarged  opening  thus  ob- 
tained.    Two   sutures  were  taken   in  the   divided  vesical  neck  and   ure- 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  249 

thra  and  drainage  tubes  were  placed  through  the  urethra  into  the  bladder 
and  the  lateral  cavities  were  lightly  packed  with  gauze  and  the  wound 
closed  as  usual.  There  was  very  little  hemorrhage.  The  patient  stood  the 
operation  well.  An  infusion  of  salt  solution  was  given  on  his  return  to 
room  and  continuous  irrigation  was  begun. 

Convalescence. — The  temperature  rose  to  100.5°  on  the  night  of  the 
operation,  but  was  practically  normal  after  the  second  day.  The  cath- 
eters and  gauze  were  removed  on  the  day  following  the  operation.  Urine 
came  through  the  penis  on  the  12th  day,  and  the  perineal  fistula  closed 
on  the  16th  day.  The  patient  left  the  hospital  on  the  25th  day;  at  that  time 
he  was  able  to  retain  urine  for  three  hours,  had  no  pain,  no  incontinence 
except  a  tendency  to  dribble  when  the  bladder  became  full.  A  catheter 
passed  without  meeting  any  obstruction,  found  no  residual  urine,  a  blad- 
der capacity  of  180  cc.  Urine  was  slightly  cloudy,  and  contamed  pus 
cells  and  bacilli.  The  patient  was  discharged  with  directions  to  take 
urotropin  and  to  retain  urine  as  long  as  possible  to  distend  the  bladder. 

February  1,  1905. — I  void  urine  naturally  once  at  night,  and  every  three 
or  four  hours  during  the  day  in  large  amounts  at  a  time.  I  suffer  no 
pain  and   consider   myself   cured. 

March  30,  1905. — Urination  is  free,  he  does  not  arise  at  night,  has 
perfect  control,  no  dribbling.  Erections  and  sexual  desire  are  return- 
ing and  intercourse  is  again  possible.  The  wound  is  completely  healed. 
A  silver  catheter  passes  without  meeting  an  obstruction  and  finds  no 
residual  urine.  The  bladder  capacity  is  large,  the  tonicity  excellent. 
Urine  contains  pus  cells  and  bacilli. 

November  30,  1905. — Letter.  I  do  not  get  up  at  night  to  void,  and  uri- 
nate every  three  or  four  hours  during  the  day  in  a  large  stream  and 
without  pain.  I  have  erections  and  my  general  health  is  excellent.  Ex- 
amination of  the  calculus  showed  pure  uric  acid. 

May  7,  1906. — 'Letter.  I  void  urine  naturally  about  every  four  hours 
during  the  day  and  do  not  have  to  get  up  at  night.  I  suffer  no  pain. 
Have  erections  occasionally.  My  general  health  is  good,  I  have  gained 
in  weight,  and  I  consider  myself  cured. 

Pathological  report. — iThe  specimen,  G.  U.  95,  consists  of  the  two  lat- 
eral lobes  of  the  prostate,  each  removed  in  one  piece,  and  weighs  about 
19  gm.  The  right  lobe  is  the  larger,  weighs  12  gm.  and  measures  3.5 
X  2.5  X  2  cm.  The  surface  is  fairly  smooth  with  a  few  lobules.  Sec- 
tion shows  considerable  fibrous  stroma  with  small  spheroids  and  a  fair 
number  of  dilated  acini.  The  left  lobe  weighs  9  gm.,  measures  3x2 
X  1.5  cm.,  is  oval  in  shape,  and  shows  considerable  stroma,  dilated  ducts, 
and  one  large  spheroid.  The  consistence  is  everywhere  elastic.  No 
mucous  membrane,  no  ejaculatory  ducts,  no  calculus  in  prostate.  A 
large  oxalate  calculus  about  5  cm.  in  diameter  as  shown  in  photograph 
(see  Fig.  35)   has  been  removed. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  distinctly 
glandular  type.    The  acini  are  dilated,  and  possess  irregular  lumina.     The 


250  Eugli  H.  Young. 

stroma  in  the  lobules  is  very  insignificant  in  amount,  there  being  often  but 
very  slender  bands  of  interstitial  tissue  between  the  acini.  The  stroma  is 
very  rich  in  muscle,  which  would  seem  to  be  somewhat  in  excess  of  the 
connective  tissue.  Some  few  areas  of  round  celled  infiltration  are  present 
in  the  stroma.  Numerous  corpora  amylacea  are  present  in  the  ducts.  An 
occasional  acinus  is  seen  containing  some  leucocytes  and  granular  debris 
with  no  change  in  the  epithelium  of  the  acinous  nor  any  periacinous 
infiltration. 

Case  48. — Moderate  hypertrophy  of  lateral  loies.  Very  little  median 
enlargement.     Several  calculi  in   hladder.     Cured.     Followed  20  months. 

No.  777.    J.  P.  W.,  age  75,  admitted  September  19,  1904. 

Complaint. — "  Bladder  trouble." 

No   history   of   gonorrhoea. 

Present  illness  began  about  10  years  ago  with  difficulty  and  frequency 
of  urination,  which  has  gradually  increased.  Four  years  ago  had  an 
attack  of  pain  in  the  left  back  and  radiating  thence  to  the  left  groin,  and 
lasting  about  three  hours.  Since  then  urination  has  been  painful.  Hema- 
turia has  occurred  frequently. 

S.  P. — ^The  patient  now  urinates  about  every  15  minutes  night  and 
day.  Micturition  very  painful  and  sometimes  accompanied  with  blood. 
He  uses  a  catheter  about  once  a  day,  but  withdraws  only  a  small  amount 
of  urine  and  has  to  urinate  again  in  an  hour. 

Sexual  poxcer. — Sexual  desire  is  gone  and  erections  are  very  slight. 
Has  not  had   intercourse  for  four  j-ears. 

Examination. — The  patient  is  a  weak,  sick-looking  man,  very  ema- 
ciated and  pale.  The  lungs  are  emphysematous,  and  there  is  a  slight 
systolic  murmur  at  the  base  of  the  heart.  The  area  of  cardiac  dullness 
is  considerably  increased.  Palpation  of  the  hypogastric  area  is  painful. 
Genitalia  negative. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth,  evidently  not 
malignant. 

Cystoscopic  examination. — ^Catheterization  produces  hemorrhage  and 
the  bladder  is  very  irritable  and  small.  Cystoscope  shows  a  vesical  cal- 
culus, but  the   examination   is   unsatisfactory. 

Urinalysis. — Acid  1020,  no  sugar,  no  albumin,  urea  5  gm.  to  liter, 
pus  and  epithelium. 

Operation,  September  21,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique,  removal  of  vesical  calculi.  The  lateral  lobes  were 
very  small,  adherent,  and  when  removed  measured  only  about  2  cm.  in 
diameter.  No  median  enlargement  was  removed.  The  urethra  was  di- 
vided along  the  left  lateral  wall  and  several  calculi  easily  extracted. 
The  largest  measures  3x2x1  cm.  in  size.  The  ejaculatory  ducts  were 
preserved.  The  wound  was  closed  as  usual  with  double  drainage  tubes 
and  gauze  for  the  lateral  cavities.  The  patient  stood  the  operation 
very  well.  The  pulse  at  the  beginning  was  104°,  was  100°  at  the  end, 
and   on  return  to  the  ward  was   72°.     Three  hours   after  the   operation 


study  of  lJ/5  Cases  of  'Perineal  Prostatectomy.  251 

the  pulse  was  70,  but  the  respirations  became  extremely  shallow  and 
rapid  and  after  a  few  minutes  imperceptible.  He  was  given  strychnine 
grains  1-20  and  an  infusion  of  salt  solution  (which  for  some  reason  had 
been  omitted)  was  started.  He  also  received  morphia  grains  Ys  hy- 
podermically.  After  half  an  hour  his  breathing  became  more  natural, 
and  two  hours  afterwards  was  24  to  the  minute  and  pulse  90. 

Convalescence. — 'The  patient  suffered  considerable  pain  for  24  hours 
after  the  operation  and  received  half  a  grain  of  morphia.  After  that 
he  convalesced  well,  but  had  a  temperature  which  reached  101°  almost 
every  day  for  two  weeks,  after  which  it  was  normal.  The  irrigation  was 
stopped  at  the  end  of  12  hours,  and  the  gauze  and  tubes  were  removed  on 
the  third  day.  He  was  up  in  a  chair  on  the  seventh  day,  and  the  urine 
was  coming  partly  through  the  anterior  urethra.  Urination  continued 
painful  for  three  weeks.  The  patient  was  discharged  on  the  34th  day 
in  good  condition,  voiding  urine  through  the  urethra,  but  at  frequent 
intervals.     The  fistula  closed  completely  on  the  27th  day. 

November  8,  1904- — iThe  patient  says  that  he  is  more  comfortable 
and  in  better  health  than  he  has  been  for  years.  During  the  day  he 
urinates  every  three  hours  and  at  night  every  hour.  He  has  a  slight 
burning  on  urination,  but  no  pain  and  no  dribbling.  The  perineal 
wound  is  entirely  healed  and  has  been  since  the  27th  day.  A  catheter 
passes  with  ease,  shows  no  evidence  or  obstruction,  finds  40  cc.  residual 
urine,  a  contracted  bladder  which  can  be  dilated  forcibly  up  to  210  cc. 
Is  to  return  for  dilatation  of  bladder  by  hydraulic  pressure  every  day. 

Novemder  11,  i5(34-— 'Bladder  dilated  up  to  250  cc. 

Novemier  25,  1904- — 'The  bladder  has  received  no  treatment  since  last 
note.  Urination  every  two  or  three  hours,  bladder  capacity  300  cc.  on 
forced    distention. 

November  30,  190-5. — ^^Letter.  Urination  three  times  during  the  day 
and  three  at  night,  about  one-half  pint  at  a  time;  no  pain,  no  fistula. 
I  consider  myself  cured,  have  no  erections.  My  general  health  is  ex- 
cellent. 

February  14,  1906. — 'Letter.  I  am  in  perfect  health,  and  can  hold  my 
urine  easily  from  three  to  five  hours. 

May  8,  1906. — iThe  patient  returns  for  examination.  He  says  he  voids 
urine  at  intervals  of  four  or  five  hours  during  the  day,  and  once  or 
twice  at  night,  from  eight  ounces  to  a  pint  at  a  time.  He  suffers  no 
pain,  except  slight  discomfort  when  the  bladder  becomes  too  full. 
He  has  erections  occasionally,  but  not  sufficient  for  intercourse. 
His  general  health  is  good,  has  gained  25  pounds  in  weight,  and  he  con- 
siders himself  cured.  A  catheter  passes  with  ease  and  finds  5  cc.  resid- 
ual urine,  bladder  capacity  350  cc.     Rectal  examination  negative. 

Pathological  report.— 'The  specimen,  G.  U.  96,  consists  of  the  two  lat- 
eral lobes  of  the  prostate  removed  in  eight  small  pieces  and  weighing 
in  all  IS  gm.  The  right  lobe  consists  of  two  pieces,  1.5  x  1.5  x  .5  cm. 
and  2  X  .5  X  .5  in  size  respectively.     The  tissue  is  firm,  homogeneous  and 


252  Hugh  H.  Young. 

shows  definite  arrangement  in  lobules.  Considerable  fibrous  tissue  is 
present  in  the  smaller  piece.  The  left  lobe  consists  of  six  small  pieces 
of  tissue  mostly  in  the  shape  of  spherical  masses.  On  section  they  show 
gland  tissue  with  intervening  stroma.  Tm'o  stones  have  been  removed, 
the  larger  weighing  13  gm.,  and  the  smaller  6  gm. 

Microscopic  examination. — The  hypertrophy  is  rather  of  the  fibro- 
muscular  type  with  here  and  there  areas  fairly  rich  in  acini.  In  these 
more  glandular  areas  the  acini  are  for  the  most  part  dilated  with  oc- 
casional cystic  degeneration,  while  the  lumina  have  considerable 
complexity  of  outline.  The  stroma  contains  a  fair  amount  of 
muscle,  and  there  is  present  considerable  embryonic  connective  tissue 
formation  with  some  round  cell  infiltration.  In  the  areas  where  the 
stroma  predominates  the  acini  are  rather  small,  apparently  regular  in 
outline,  although  sometimes  elongated  apparently  from  compressioa 
The  epithelium  lining  the  ducts  is  normal.  Within  the  stroma  there 
is  much  spindle  celled  tissue  formation  and  some  round  cell  infiltration. 
Around  some  of  the  acini  there  has  been  considerable  new  connective 
tissue  formation  with  some  infiltration  of  round  and  polynuclear  cells, 
and  degenerated  epithelial  cells  and  granular  debris  are  seen  within 
the  ducts.  One  sees  an  occasional  nodule  in  which  only  vestiges  of 
acini  persist,  and  composed  almost  entirely  of  fibrous  tissue,  an  insig- 
nificant amount  of  muscle  fibers  being  present.  These  nodules  are  en- 
capsulated, the  capsule  being  formed  of  condensed  stroma  and  contain- 
ing compressed,  elongated  acini. 

Case  49. — Moderate  enlargement  of  lateral  lobes  of  prostate.  Cath- 
eter one  year.     'Nephritis.     Uremia.     Cured. 

No.  1329.    A.  D.  C,  age  82,  widower,  admitted  September  1,  1904. 

Complaint. — "  Retention  of  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  about  three  years  ago  with  difficulty  in  urina- 
tion. About  a  year  ago  he  had  retention  of  urine  for  the  first  time,  and 
since  then  has  catheterized  himself  on  this  account  three  or  four  times. 
He  has  had  no  pain  except  when  the  bladder  has  been  distended,  no 
hematuria  except  after  catheterization.  During  the  past  year  he  has 
had  to  get  up  two  to  three  times  at  night  to  urinate. 

S.  P. — The  patient  now  has  complete  retention  of  urine  and  has  been 
unable  to  use  his  catheter. 

Sexual  powers. — No  note  made. 

Examination. — (The  patient  is  a  very  weak  looking  man,  emaciated, 
lips  pale,  and  is  apparently  suffering  great  pain.     Lungs  are  clear. 

Heart. — ^There   is  a  marked   systolic  murmur   at  the  apex. 

Abdomen. — The  hypogastric  region  is  enlarged  and  large  tender  blad- 
der is  palpable.  There  is  an  inguinal  hernia  on  the  right  side  and  the 
right   testicle    is   enlarged. 

Rectal. — The  prostate  is  very  much  enlarged,  smooth,  firm,  but  not 
extremely  hard,  and  the  upper  border  is  difficult  to  reach.  The  seminal 
vesicles   cannot    be   felt. 


tStiidy  of  lJf5  Cases  of  'Perineal  Prostatectomy.  253 

Urethral. — The  patient  is  unable  to  void  urine,  and  has  had  complete  re- 
tention since  yesterday.  A  catheter  is  passed  with  ease  and  1000  cc. 
urine   withdrawn. 

Cystoscopy. — ^Record   lost. 

Preliminary  treatment. — A  permanent  catheter  was  fastened  in  the 
urethra  for  continuous  drainage.  Patient  was  given  urotropin  and 
water  in  abundance.  He  suffered  considerably  from  paroxymal  pains 
in  the  bladder.  He  was  very  weak  and  there  was  considerable  pufli- 
ness  of  the  eyelids. 

Urinalysis. — ^^Very  bloody,  1016,  alkaline,  considerable  albumin,  many 
pus  cells,  red  blood  corpuscles,  no  casts.  Total  urea  11.3  gm.  After  three 
weeks  the  patient's  condition  was  still  bad,  he  suffered  pain  and  tender- 
ness over  the  bladder,  1200  cc.  urine  was  secreted  daily,  and  occasion- 
ally granular  casts  were  found.  The  patient  was  still  unable  to  void 
urine,  and  although  his  condition  became  desperate  it  was  thought  best  to 
perform  perineal  prostatectomy  for  drainage.  There  had  been  a  fever 
ranging  from  100°  to  101°  and  occasionally  up  to  102°. 

Operation,  September  2Jf,  1904- — Spinal  anesthesia,  cocaine  %  of  a 
grain.  Perineal  prostatectomy  by  the  usual  technique.  The  lateral 
lobes  which  measured  4x4x5  cm.  in  size  were  each  enucleated  with- 
out injury  of  the  urethra  or  the  ejaculatory  ducts.  Examination  showed 
no  median  lobe  enlargement.  The  wound  was  closed  as  usual  with 
double  tube  drainage  and  light  packs  for  the  lateral  cavities.  The  pa- 
tient stood  the  operation  well,  his  pulse  at  the  end  being  95.  Spinal 
anesthesia  was  entirely  satisfactory.  Infusion  and  continuous  irriga- 
tion   on    return    to    ward. 

Convalescence. — The  patient  reacted  well,  there  was  no  nausea,  no  head- 
ache, pulse  did  not  go  above  100°  and  the  patient  was  comfortable  and 
drank  water  in  abundance.  The  temperature  rose  to  99.6°  on  the  day 
after  the  operation,  and  returned  to  normal  on  the  fourth  day.  Later 
on  there  was  a  slight  temperature  (100.7°)  for  a  few  days,  but  the  con- 
valescence was  uninterrupted.  The  irrigation  was  discontinued  on  the 
second  day,  when  the  gauze  and  catheters  were  removed,  and  the  pa- 
tient was  placed  in  a  chair.  The  urine  came  through  the  anterior  urethra 
on  the  second  day  after  the  operation  and  the  perineal  fistula  closed 
completely  on  the  12th  day.  The  patient  was  discharged  from  the  hos- 
pital on  the  21st  day.  His  general  condition  was  fair  and  improving. 
The  wound  had  been  closed  for  nine  days,  and  he  was  free  from  pain. 
Urine  was  voided  naturally  but  frequently  and  his  control  was  weak. 

February  22,  1906. — Report  by  daughter.  The  wound  remained  healed 
and  the  patient  voided  urine  naturally  without  pain,  only  once  at  night 
and  at  normal  intervals  in  the  day.  On  January  12,  1905,  the  patient 
had  an  apoplectic  stroke  and  he  died  February  12,  1905.  He  was  per- 
fectly  cured  of  his  urinary  trouble. 

Pathological  report. — The  specimen,  G.  U.  99,  consists  of  the  two  lat- 
eral  lobes   removed   in  five   pieces,   and   weighs   about   33   gm.     The  left 


254  Hugli  H.  Young. 

lobe  has  been  removed  in  one  piece  and  measures  5  x  3.5  x  2.5  "cm.,  and 
weighs  19  gm.  It  is  smooth,  firm  but  elastic,  and  is  not  lobulated. 
The  sections  show  considerable  gland  tissue  with  a  few  dilated  ducts 
and  a  small  amount  of  stroma.  The  right  lobe  has  been  removed  in 
four  pieces  and  weighs  14  gm.  In  general,  the  appearance  is  the  same 
as  that  of  the  left.  No  mucosa,  no  ejaculatory  ducts,  no  calculi  removed. 
Microscopic  examination. — The  hypertrophy  is  of  the  glandular  type 
with  moderate  dilatation  of  the  ducts,  some  cystic  degeneration,  and  in 
areas  quite  marked  evidence  of  glandular  proliferation.  The  glandular 
tissue  is  partly  arranged  in  lobules,  but  even  outside  these  lobular  areas 
the  tissue  is  quite  rich  in  acini.  The  stroma  is  mostly  composed  of  fibrous 
tissue,  but  there  is  a  fair  amount  of  smooth  muscle  present.  Some  chronic 
prostatitis. 

Case  50. — Moderate  enlargement  of  lateral,  median  and  anterior  lobes. 
Residual  urine  1100  cc.  Atonic  Madder.  Imperfect  result.  Residuum 
300  cc.  Bottini  operation,  slight  improvement.  Ultimate  result:  Catheter 
not  used.     Urination  satisfactory  hut  frequent.    Followed  18  months. 

No.  722.    M.  G.,  age  71,  widower,  admitted  September  7,  1904. 

Complaint. — "  Bladder  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  30  years  ago  with  slight  difficulty  of  urin- 
ation, this  gradually  increased  and  for  the  past  25  years  the  patient  has  had 
to  arise  from  10  to  12  times  at  night  to  urinate.  About  five  years  ago 
he  had  complete  retention  of  urine  and  had  to  be  catheterized,  but  has 
never  been  catheterized  since.  The  amount  voided  each  time  is  small  and 
generally  accompanied  by  pain  in  the  penis. 

S.  P. — The  patient  voids  urine  about  six  times  during  the  night  and  about 
as  often  in  the  day.  He  has  no  incontinence,  but  the  stream  is  small 
and  slow  and  accompanied  by  slight  pain  in  the  bladder  and  penis.  He 
is  very  short  of  breath,  and  he  has  lost  20  pounds  in  weight. 

Sexual  potcers. — He  has  had  no  erections  or  sexual  desire  for  several 
years. 

Examination. — The  patient  is  well  nourished  and  his  lips  are  of  good 
color.  Pulse  92  to  the  minute,  regular,  of  good  volume  and  good  tension 
and  the  vessel  wall  is  not  palpable.  The  lungs  are  negative.  The  region 
of  cardiac  dullness  extends  upward  to  the  third  rib  and  outward  to  the 
nipple  line.  The  sounds  at  the  apex  and  base  are  clear,  but  distant.  Ab- 
dominal examination  is  negative.  Large  inguinal  hernias  are  present. 
Genitalia  are  negative.  The  prostate  is  slightly  enlarged,  soft,  smooth, 
and  elastic;  no  induration  in  the  region  of  the  seminal  vesicles. 

Cystoscopic  examination. — A  catheter  passes  with  ease  withdrawing 
1100  cc.  residual  urine.  Bladder  tonicity  is  very  poor.  The  cystoscope 
shows  a  slight  median  bar  behind  which  both  ureters  can  be  seen;  mod- 
erately hypertrophied  lateral  lobes,  and  a  small  but  prominent  anterior 
lobe  which  is  separated  from  the  lateral  lobes  by  a  sulcus  on  each  side 
(but  more  continuous  with  the  left  than  the  right).  The  bladder  is 
considerably  trabeculated,  but  not  inflamed. 


study  of  145  Cases  of  •Perineal  Prostatectomy.  255 

Urinalysis.- — The  urine  is  clear,  contains  no  pus  cells  or  bacteria. 
Complete  analysis  lost. 

September  22. — After  two  weeks  catheterization  the  urinalysis  was  as 
follows:  The  total  amount  voided  in  24  hours  was  2100  cc.  Urea  5.5  gr. 
Urine,  acid,  sp.  gr.  1010,  albumin  in  small  amount.  Microscopically,  red 
blood  corpuscles,  epithelium,  no  casts. 

On  September  22,  total  amount  of  urine  2700  cc.  Urea  7.5  gr.  Sp.  gr. 
1009,  acid,  albumin  in  small  amount. 

Preliminary  treatment. — The  patient  was  catheterized  three  times  a  day 
for  20  days.  Under  this  treatment  the  patient  improved.  Shortness  of 
breath  became  much  less,  the  urine  of  better  specific  gravity  and  the  patient 
stronger.  He  was  able  to  void  urine  in  amounts  varying  from  90  to  120  cc, 
but  residual  urine  from  1100  to  1500  cc.  was  constantly  present  at  first. 
After  three  weeks  catheterization  his  residual  urine  varied  from  640  to 
900  cc. 

Operation,  September  27,  1904- — Spinal  cocainization.  Perineal  prostat- 
ectomy by  the  usual  technique.  Lumbar  puncture  was  made  between  the 
third  and  fourth  vertebrae  and  after  the  spinal  iiuid  had  begun  to  flow  a 
syringe  containing  one-third  gr.  of  cocaine  was  attached  to  the  needle, 
the  bulb  filled  with  spinal  fluid  and  the  cocaine  allowed  to  dissolve  for  a 
minute  and  a  half  before  being  injected.  The  piston  was  then  drawn  back 
and  forth  two  or  three,  times  so  as  to  empty  the  syringe  of  all  cocaine. 
The  patient  was  put  immediately  on  the  table  and  the  operation  begun 
within  three  minutes.  The  patient  experienced  no  pain  throughout  the 
entire  operation.  The  right  lateral  lobe  was  only  slightly  hypertrophied 
and  was  removed  in  one  piece.  In  removing  the  left  lateral  lobe  an 
effort  was  made  to  engage  the  anterior  lobe  and  to  remove  it  in  one 
piece  with  the  left  lateral.  The  amount  of  tissue  removed  was  distinctly 
larger  than  that  from  the  right  side  but  it  was  impossible  to  make  out 
distinctly  the  demarcation  between  the  left  and  anterior  lobe.  It  was 
impossible  to  engage  the  median  bar  which  was  very  slight  and  after  the 
tractor  had  been  removed  the  finger  was  introduced  and  examination 
seemed  to  show  that  the  bar  was  so  small  and  adherent  that  it  was  not 
thought  advisable  to  produce  the  traumatism  necessary  to  excise  it.  The 
urethra  and  ejaculatory  ducts  were  preserved,  a  slight  tear  being  made  in 
the  right  lateral  wall  of  the  urethra.  The  wound  was  closed  with  slight 
packing  for  the  lateral  cavities,  double  tube  drainage  for  the  bladder,  and 
continuous  irrigation  on  the  table  and  after  return  to  the  ward.  The 
patient's  pulse  at  that  time  was  96  and  his  condition  was  excellent.  Sub- 
mammary infusion  of  700  cc.  was  given. 

Convalescence. — The  patient  did  well  for  the  first  24  hours  when  the 
temperature  rose  to  10-3°  and  he  became  somewhat  irrational.  On  the  fifth 
day  the  temperature  was  normal  and  patient  comfortable.  The  gauze  was 
removed  48  hours  after  the  operation  and  the  tubes  on  the  next  day. 
The  patient  was  up  in  a  wheel  chair  on  third  day  and  was  walking  at  the 
end  of  a  week.  Urine  passed  through  the  penis  on  the  seventh  day,  but 
the  perineal  fistula  was  still  open  on  his  discharge  from  the  hospital  on 


256  Hugh  H.  Young. 

the  37th  day.  Examination  at  that  time  showed  the  patient  in  excellent 
condition,  free  from  pain,  voiding  urine  at  intervals  of  from  five  to  six 
hours,  but  with  some  incontinence  when  walking  about.  Perineal  fistula 
is  about  5  mm.  in  diameter  and  unhealthy  in  appearance.  A  silver 
catheter  passed  into  the  bladder  with  ease,  meeting  no  obstruction  nor 
evidence  of  stricture  and  finding  200  cc.  residual  urine  and  a  bladder 
capacity  of  700  cc.  The  urine  was  acid  and  contained  pus  and  bacilli. 
The  fistula  is  thoroughly  curetted  with  a  gimlet  curette. 

October  29,  190^. — The  fistula  is  now  closed. 

February  9,  1905. — The  patient  returned  to  the  hospital.  He  says  that 
one  week  ago  a  small  abscess  developed  in  the  region  of  the  perineal 
fistula  and  was  incised  by  a  physician.  He  voids  urine  about  12  times 
during  the  day  and  frequently  at  night,  and  there  is  more  or  less  dribbling 
while  he  is  in  bed.  He  suffers  no  pain,  his  general  health  is  improved 
rapidly,  and  he  has  gained  40  pounds  in  weight. 

Examination. — The  perineal  fistula  persists,  a  few  drops  escaping 
through  it. 

Rectal  examination. — In  the  region  of  the  prostate  is  a  cicatrix  much 
smaller  than  the  normal  prostate.  There  is  no  unusual  induration  and 
the  seminal  vesicles  are  not  enlarged.  The  silver  catheter  passes  with 
ease  and  finds  400  cc.  residual  urine.  The  vesical  tonicity  seems  fairly 
good.  The  cystoscope  shows  very  little  trabeculation  and  no  pouch  form- 
ation. A  small  median  bar  is  present  with  a  definite  bas  fond  behind  it, 
but  it  is  possible  to  see  the  ureters  and  the  interureteral  bar.  A  slight 
enlargement  of  the  left  lateral  lobe  is  present.  The  anterior  lobe  is 
absent.  With  the  finger  in  the  rectum  and  cystoscope  in  the  urethra  a 
definite  increase  in  the  median  portion  of  the  prostate  is  felt.  The 
total  length  of  the  enlargement  being  about  2  cm. 

Note. — In  reviewing  this  history  it  seemed  evident  that  the  small 
median  bar  which  had  not  been  removed  at  operation  was  responsible  for 
the  residual  urine,  which  was  present.  It  therefore  seemed  advisable  to 
divide  this  by  a  Bottini  operation. 

Operation,  February  10.  1905. — Cocaine  four  per  cent  in  the  urethra. 
Bottini  operation  with  blade  No.  2,  1.2  cm.  high.  Two  cuts,  one  posterior 
1.5  cm.  long  and  one  left  lateral  1.4  cm.  long,  a  current  of  45  amperes  being 
used,  blade  almost  at  white  heat.  Two  minutes  were  consumed  in  each  cut; 
the  operation  was  performed  under  the  control  of  a  finger  in  the  rectum 
and  the  amount  of  tissue  in  the  median  portion  seemed  to  be  so  slight  that 
very  short  cuts  were  made.  Immediately  after  the  operation  the  patient 
voided  25  cc.  of  the  200  cc.  which  had  been  injected  in  the  bladder. 

Convalescence.- — There  was  no  rise  of  temperature  after  the  operation, 
and  very  little  hemorrhage.  The  patient  was  walking  about  on  the 
second  day,  and  he  left  the  hospital  on  the  eighth  day,  at  which  time  the 
fistula  was  closed,  and  the  patient  was  voiding  much  more  easily  and  his 
condition  was  excellent.  A  catheter  passed  with  ease,  but  found  300  cc. 
residual  urine. 

March  23.  1905. — The  patient  says  that  after  he  returned  home  he  passed 


study  of  lJf.5  Cases  of  'Perineal  Prostatectomy.  257 

numerous  sloughs  and  had  two  fairly  considerable  hemorrhages.  He  is 
much  improved,  he  can  frequently  hold  urine  for  three  hours  during  the 
day,  and  at  night  sleeps  three  or  four  hours  without  urinating.  A  pin 
point  fistula  is  still  present  through  which  a  few  drops  still  escape.  He 
has  complete  control  and  has  no  incontinence,  and  no  dribbbling.  His 
general  health  is  excellent.  A  catheter  passes  with  ease  and  finds  250  cc. 
residual  urine.  The  bladder  capacity  is  740  cc.  and  the  tonicity  is  poor. 
Kollmann  dilator  passes  with  ease  and  can  be  dilated  up  to  35  F.  without 
meeting  any  resistance,  and  causing  very  little  hemorrhage. 

February  5,  1906. — Letter.  The  fistula  closed  about  10  days  after  I  last 
saw  you  (March  23,  1905),  and  has  remained  healed.  I  void  urine  natur- 
ally about  a  dozen  times  during  the  day  and  six  times  at  night,  from  one- 
quarter  to  three-quarters  of  a  pint  at  a  time.  Urination  is  free  and  satis- 
factory. The  amount  passed  in  24  hours  is  three  quarts.  I  have  no  incon- 
tinence, but  there  is  a  slight  dribbling  at  the  end  of  urination,  a  few 
drops.  My  general  health  is  fair,  and  the  result  of  the  operation  is  entirely 
satisfactory. 

Pathological  report. — The  specimen,  G.  U.  100,  consists  of  the  two  lateral 
lobes  of  the  prostate  removed  in  five  pieces,  and  weighing  in  all  G-14. 
The  right  lobe  is  in  two  pieces  and  weighs  G-6.  The  tissue  is  elastic,  but 
rather  firm,  in  places  lobulated  and  in  others  smooth.  On  section  the  sur- 
face is  homogeneous  except  for  small,  dilated  acini.  The  entire  lobe 
measures  3  x  2.5  x  1.5  cm.  The  left  lobe  is  in  three  pieces,  weighs  G-8, 
and  measures  in  all  3.5  x  3  x  2.5  cm.  It  is  similar  in  appearance  to  the 
right,  there  being  considerable  stroma  and  a  rather  thick  capsule. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  although 
there  is  present  in  areas  considerable  stroma.  The  acini  are  moderately 
dilated  with  occasional  cystic  dilatation.  The  lumina  of  the  culs-de-sac 
show  the  usual  intraacinous  papillomatous-like  proliferation.  The  stroma 
contains  a  fair  amount  of  muscle,  but  the  connective  tissue  is  somewhat 
in  excess.  There  is  present  quite  a  marked  prostatitis  with  areas  of  much 
periacinous  inflammatory  tissue  formation.  The  arteries  show  practically 
no  thickening. 

Case  51. — Small  rounded  median  lobe.  Residuum  50  cc.  Bladder  con- 
tracted— capacity  IJ/O  cc.  Left  hospital  much  improved.  Recurrence  of 
obstruction  four  months  later. 

No.  1328.     F.  H.,  age  67,  married,  admitted  August  1,  1904. 

Complaint. — "  Inability  to  pass  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  two  years  ago  with  difficulty  of  micturition. 
Since  then  there  has  been  considerable  straining  and  increased  fre- 
quency of  urination,  but  he  got  along  well  until  10  days  ago  when  com- 
plete retention  of  urine  came  on,  requiring  catheterization.  Since  then 
he  has  voided  voluntarily,  but  at  intervals  of  from  10  to  15  minutes. 
He  has  lost  about  20  pounds  during  the  past  year.  Sexual  powers  lost, 
no   intercourse  for   one  year. 

Examination. — The  patient  is  a  thin,  nervous-looking  man. 


258  Hugh  H.  Young. 

Genitalia. — -A  small  hydrocele  is  present  on  both  sides.  A  large  fem- 
oral hernia  is  present  in  the  right  groin. 

Rectal. — The  prostate  is  only  slightly  but  equilaterally  enlarged, 
rounded,  smooth,  elastic,  except  at  the  upper  end  where  there  is  indu- 
ration on  both  sides.  The  seminal  vesicles  are  not  palpable,  and  there 
are  no  glands  to  be  felt.     The  rectal  mucosa  is  soft  and  not  adherent. 

Cystoscopic. — ^A  coude  catheter  passes  with  ease  and  finds  only  20  cc. 
residual  urine.  The  bladder  capacity  is  140  cc.  The  cystoscope  shows 
a  small  sessile  rounded  median  lobe  with  a  deep  sulcus  on  each  side. 
The  lateral  lobes  are  not  enlarged.  In  the  base  of  the  bladder  an  irregu- 
lar mass,  dark  brown  in  color  is  seen,  probably  an  old  blood  clot  break- 
ing up.  No  evidence  of  vesical  tumor  is  present.  With  finger  in  rec- 
tum and  cystoscope  in  urethra  a  slight  increase  in  the  median  portion 
of  the  prostate  is  detected. 

Uritialysis. — Clear,  1007,  acid,  no  sugar,  albumin,  a  trace.  Microscop- 
ically, pus  in  small  amount,  and  a  few  granular  casts. 

Preliminary  treatment. — Urotropin,  water,  intravesical  irrigations,  and 
occasional  catheterization.  The  patient  continued  to  pass  urine  very 
frequently  in  small  amount  and  with  difficulty,  but  the  catheter  found 
only  from  20  to  50  cc.  residual  urine.  Attempts  were  made  to  dilate 
the  bladder  by  hydraulic  pressure,  but  without  success,  and  at  the  end 
of  two  months  the  patient's  condition  was  the  same  as  on  entrance,  and 
although  there  was  very  little  residual  urine,  prostatectomy  was  de- 
cided  upon. 

Operation,  September  30,  190^. — Ether.  Perineal  prostatectomy  by 
the  usual  technique.  The  lateral  lobes  were  quite  adherent  and  had  to 
be  dissected  from  the  capsule  and  urethra.  The  median  lobe  was  drawn 
down  by  the  tractor  so  that  it  presented  suburethrally,  but  it  was  easily 
removed  through  one  of  the  lateral  cavities,  only  a  small  tear  being 
made.  The  usual  closure  was  made  with  double  tube  drainage  and  light 
packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well.  Pulse 
at  the  end  105°.     Continuous  irrigation  on  return  to  ward. 

Convalescence. — ^The  patient  reacted  well.  The  temperature  rose  to 
100.5°  two  days  after  the  operation,  but  remained  normal  after  the 
fourth  day.  Gauze  and  tubes  were  removed  within  48  hours,  and  the 
patient  was  out  of  bed  and  in  good  condition  three  days  after  the  op- 
eration. The  perineal  wound  healed  completely  within  20  days,  and 
the  urine  was  voided  in  a  large  stream.  The  bladder  capacity  had  in- 
creased to  340  cc. 

On  the  22d  day  an  operation  for  femoral  hernia  was  performed.  Fol- 
lowing this  operation  the  patient  had  bronchitis,  and  a  temperature  of 
102.7°,  but  after  five  days  the  temperature  remained  normal,  and  the 
patient  was  discharged  November  26.  Examination  showed  no  residual 
urine,  and  a  bladder  capacity  of  300  cc.  Urine  voided  in  a  large  stream 
with  perfect  control,  at  intervals  of  an  hour.  Urine  acid,  albumin  a 
trace,  sp.  gr.  1020;  microscopically,  pus  cells.  General  condition  excel- 
lent.   The  cystoscope  shows  a  practically  normal  prostatic  orifice. 


study  of  1J/.5  Cases  of  'Perineal  Prostatectomy.  259 

May  19,  1906. — ^Family  report  that  the  patient  committed  suicide  Jan- 
uary, 1905,  about  four  months  after  the  operation.  They  report  that 
urination  was  not  entirely  satisfactory,  as  he  voided  frequently  and 
suffered  pain.  Several  days  before  death  urine  was  coming  in  driblets 
at  very  frequent  intervals,  and  he  was  catheterized  by  a  physician  who 
reports  that  he  found  about  half  a  pint  of  urine  present.  After  that  the 
patient  voided  fairly  well  for  two  or  three  days,  when  urination  again 
became  difficult  and  catheterization  was  again  necessary.  Two  days  later 
he  committed  suicide. 

PatJiological  report.— The  specimen,  G.  U.  103,  consists  of  the  two 
lateral  lobes  each  in  one  piece  and  the  middle  lobe  in  two  pieces,  and 
weighs.  13  gm.  The  right  lobe  measures  2.5  x  2  x  1.5  cm.,  is  somewhat 
irregular,  elastic,  and  on  section  shows  a  fairly  thick  capsule  and  gland 
tissue  with  considerable  stroma;  it  weighs  4  gm.  The  left  lobe  weighs 
5  gm.,  measures  3  x  2.5  x  1.5  cm.,  feels  harder  than  the  right,  but  on 
cross  section  considerable  gland  tissue  is  evident.  The  median  lobe 
weighs  4  gm.  and  measures  2.5  x  2  x  1.5  cm.  On  section  several  cavities 
filled  with  bloody  secretion  are  seen.  No  mucous  membrane,  no  ducts, 
no   calculus. 

Microscopic  examination. — The  tissue  of  the  left  and  middle  lobes  pre- 
sents small  circumscribed  areas  of  typical  adenomatous  hypertrophy,  but 
there  is  more  stroma  as  a  whole  than  gland  tissue.  The  fibrous  tissue  pre- 
dominates in  the  stroma.  Some  areas  of  prostatitis  are  present.  In  the 
right  lateral  lobe  the  amount  of  gland  tissue  present  is  insignificant.  Many 
of  the  acini  are  small  and  compressed,  while  the  stroma  is  largely  composed 
of  fibrous  tissue.  Some  areas  of  round  cell  and  polynuclear  cell  infil- 
tration. The  hypertrophy  in  the  right  lateral  lobe  is  of  a  distinctly  fibro- 
muscular  type,  while  that  in  the  middle  and  left  lobes  is  mixed,  both 
fibro-muscular  and  glandular  elements  being  present  in  varying  pro- 
portions. 

Case  52. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Slight 
uremia  six  m,onths.  Nausea  and  vomiting.  Operation  to  supply  drainage. 
Death  on  fourteenth  day.     Autopsy.    Double  pyonephrosis. 

No.  801.     W.  W.,  age  65,  married,  admitted  September  20,  1904. 

Complaint. — "  Difficulty  of  urination." 

No   history   of   gonorrhoea. 

Present  illness  began  three  years  ago  with  difficulty  in  urination. 
About  the  same  time  he  began  to  suffer  pain  in  the  region  of  the  right 
kidney.  The  obstruction  to  urination  became  gradually  greater,  and 
during  the  last  six  months  he  has  voided  urine  about  every  hour  night 
and  day,  and  has  frequently  suffered  considerable  pain  before  and  after 
urination.  During  the  past  three  months  he  has  suffered  with  consid- 
erable nausea,  vomiting,  and  lack  of  appetite.  His  physician  writes  that 
he  thinks  he  has  been  constantly  uremic  during  this  time.  He  has  lost 
considerably  in  strength  and  weight  (30  pounds),  but  never  had  com- 
plete retention  of  urine  until  yesterday,  when  attempts  of  his  physician 
to  pass  filiforms  and  catheters  were  unsuccessful. 
Vol.  XIV.— IS. 


260  Hugh  H.  Young. 

S.  p. — The  patient  is  unable  to  void  except  a  few  drops  at  a  time 
and  with  difficulty.     He  is  quite  ill,  has  severe  nausea  and  vomiting. 

Examination. — The  patient  looks  very  sick,  is  retching  frequently,  and 
his  breath  has  a  strong  urinary  odor.     Pulse  is  112,  hard,  intermittent. 

Chest. — The  breathing  is  mostly  abdominal.  The  percussion  note  is 
hyperresonant. 

Heart. — The  heart  is  quite  irregular,  and  there  is  a  systolic  murmur  at 
apex.  The  heart  sounds  are  feeble.  The  abdomen  is  distended,  and  a 
dilated  bladder  is  felt  which  reaches  to  the  umbilicus. 

Rectal. — The  prostate  is  very  much  enlarged,  the  right  lobe  is  the 
larger,  it  is  smooth,  regular,  firm,  but  elastic;  no  nodules  or  glands 
made  out.     The  seminal  vesicles  are  negative. 

Preliminary  treatment. — 'On  admission  an  attempt  at  catheterization 
was  made,  but  without  success,  owing  to  a  false  passage  in  the  region  of 
the  membranous  urethra.  Suprapubic  aspiration  was  performed,  but 
only  240  cc.  were  removed.  An  infusion  of  800  cc.  was  given  on  account 
of   vomiting. 

September  21,  1904- — The  patient  is  still  nauseated  and  refuses  nour- 
ishment. He  was  successfully  catheterized  to-day,  940  cc.  urine  being 
evacuated.     Retention  catheter  was  provided. 

Urinalysis. — 1008,  acid,  no  sugar,  albumin  a  trace;  microscopically, 
blood   cells. 

September  22.  1904- — Patient  uncomfortable,  vomits  small  amounts, 
temperature  99°,  pulse  88.  Drainage  2260  cc.  Liquid  diet.  Salt  solu- 
tion and  coffee  per  rectum. 

September  24- — Nausea  and  vomiting  continue.  Drainage  1860  cc. 
Sp.  gr.  1007,  urea  13  gm.  per' liter. 

September  25. — More  comfortable,   less  nausea.     Drainage   2880   cc. 
September    21. — Fairly    comfortable     day.       Temperature     98.2°,    pulse 
104.     Enjoys  his  meals. 

September  28. — Has  taken  a  turn  for  the  worse  to-day.  Has  been  in 
a  stupor  much  of  the  time  and  vomited  considerably.  Complains  of 
pain  in  urethra  and  bladder.  Refuses  nourishment.  Salt  solution  and 
potassium  citrate  have  been  continued  daily,  1600  cc.  being  given. 

September  30. — ^Patient  still  has  nausea  and  refuses  nourishment. 
Temperature  99°,  pulse  100.  Drainage  2560  cc.  Sp.  gr.  1010,  albumin 
a  trace.    Microscopically,  pus  cells,  but  no  casts.     Total  urea  30  gm. 

Kote — TThe  patient  is  not  improving  under  continuous  drainage.  The 
urethra  has  become  very  irritable,  and  the  catheter  causes  pain.  It  is 
thought  best  to  supply  perineal  drainage,  although  the  hope  of  curing 
the  patient  is  not  good. 

Operation,  September  30,  1904- — Spinal  anesthesia.  Perineal  prosta- 
tectomy by  the  usual  technique.  One-third  of  a  grain  of  cocaine  was 
used  and  with  perfect  success.  Two  moderately  enlarged  lateral  lobes 
were  easily  enucleated,  only  a  small  tear  being  made  in  the  urethra  on  one 
side.  There  was  a  small  median  enlargement  which  was  removed.  The 
wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs  for 


study  of  IJfO  Cases  of  'Perineal  Prostatectomy.  261 

the  lateral  cavities.  The  pulse  was  bad  during  part  of  the  operation, 
reaching  160,  but  it  became  better  towards  the  end  (130).  His  condition 
at  the  end  was  fair.  Infusion  on  table.  Continuous  irrigation  on  return 
to  ward. 

Convalescence. — Gauze  removed  in  24  hours,  tubes  in  48  hours.  Patient 
is  fairly  comfortable,  pulse  96  to  120,  small  and  irregular.  Infusion 
700    cc. 

October  4,  lOOJf. — Uncomfortable,  nauseated,  vomiting.  Nourishment 
refused.     Temperature   subnormal,    pulse   100. 

October  6,  1904. — Patient  weak,  vomiting  continuous.  Pulse  100,  but 
weak,  temperature  96.8°  to  98°.  Daily  infusions.  Excreting  urine 
freely.     Wound  looks  well. 

October  10. — Vomiting  and  nausea  continue.  Rectum  is  intolerant 
to  nutritive  enemata.  Is  getting  very  little  nourishment  and  becoming 
very  weak.  Temperature  96.9°  to  97°,  pulse  116.  Urine  drains  freely 
from  the  perineal  wound. 

October  1.3,  A.  M. — ^The  patient  has  continued  to  grow  worse.  Stom- 
ach and  rectum  are  both  intolerant.  He  has  had  no  nourishment  for 
several  days.  Pulse  small,  intermittent.  Temperature  95.8°  to  98°. 
Hiccough,   nausea   and  vomiting. 

P.  M. — Because  of  impossibility  of  getting  either  water  or  nourish- 
ment Into  the  patient  by  stomach,  bowels  or  rectum,  it  was  decided  to 
attempt  to  feed  him  through  a  high  enterostomy.  Accordingly,  under  co- 
caine anesthesia  an  incision  was  made  in  the  median  line  above  the 
umbilicus,  and  the  first  loup  of  small  bowel  presenting  was  sutured 
into  the  wound  preparatory  to  enterostomy.  The  patient  stood  the 
operation  very  poorly,  and  died  two  hours  later  before  the  intestine  had 
been   opened. 

Autopsy. — Autopsy  showed  double  hydropyonephrosis.  The  kidney 
pelves  were  greatly  dilated  and  the  ureters  were  each  the  size  of 
the  thumb.  There  was  a  marked  inflammation  present,  evidently  of 
old  standing.  There  were  emphysema  of  the  lungs,  chronic  fibrous  my- 
ocarditis and  maculee  tendinse. 

Note. — Operation  was  attempted  in  this  case  only  as  a  last  resort.  It 
is  evident  that  nothing  could  have  saved  him. 

Pathological  report. — ^The  specimen,  G.  U.  101,  consists  of  the  median 
and  lateral  lobes  of  the  prostate  removed  in  four  large  and  two  small 
pieces,  and  weighing  55  gm.  The  right  lobe  measures  5.5  x  4  x  3.5  cm. 
and  weighs  32  gm.  and  consists  of  two  large  aod  two  small  pieces  with 
a  small  area  of  adherent  mucosa.  On  cross  section  the  condensation  of 
fibrous  tissue  at  the  periphery  with  capsule  formation  is  moderate. 
Lobulation  and  gland  hypertrophy  are  quite  evident  on  the  cut  surface, 
and  the  glands  in  places  are  filled  with  a  brownish  green  soft  matter 
which  exudes  on  squeezing,  and  which  contains  microscopically  many  le- 
cithins, many  fine  deeply  staining  granules,  a  few  pus  cells,  and  granu- 
lar debris.  The  left  lobe  measures  ox3x2cm.  and  weighs  23  gm.  The 
middle  lobe  measures  3  x  2.5  x  2.5  cm.  and  weighs  10  gm.  Characteris- 
tics similar  to  right. 


262  Hugli  H.  Young. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one.  Some  arrangement  of  the  acini  in  lobules,  the  stroma  in  these  areas 
being  small  in  amount  and  largely  of  connective  tissue.  In  other  portions 
the  bands  of  stroma  between  the  acini  are  rather  broad.  The  stroma  con- 
tains more  connective  tissue  than  muscle,  and  there  is  a  formation  of  con- 
siderable embryonic  tissue.  There  are  some  areas  of  prostatitis.  The  ar- 
teries are  moderately  thickened. 

Case  53. — Slight  fibrous  hypertrophy  of  prostate  associated  ivith  stricture 
of  urethra.    Followed  20  months. 

No.  601.    L.  S.,  age  71,  married,  admitted  April  15,  1904. 

Complaint. — "  Stricture  of  urethra.    Catheter  life." 

Patient  had  gonorrhoea  twice  in  his  youth,  but  thinks  he  was  entirely 
cured.  Has  been  married  for  38  years  and  is  the  father  of  two  children. 
A  stricture  developed  35  years  ago  and  he  received  dilatation. 

Present  illness  began  about  five  years  ago  with  increased  frequency  of 
urination,  which  gradually  increased,  but  giving  very  little  trouble  until 
January,  1903,  when  complete  retention  of  urine  came  on.  He  was  then 
catheterized  for  10  days,  but  after  that  voided  naturally,  but  frequently. 
A  second  retention  came  on  in  November,  1903,  and  a  third  in  January, 
1904,  and  since  then  he  has  had  to  use  a  catheter  once  or  twice  a  day. 

8.  P. — The  patient  is  unable  to  void  more  than  a  few  drops  of  urine. 
He  uses  a  catheter  twice  a  day,  suffers  no  pain,  and  is  quite  comfortable. 

Sexual  poicers. — He  has  had  no  sexual  desire  for  five  years  and  no  inter- 
course, although  occasionally  there  is  a  slight  erection  in  the  morning. 

Examination. — The  patient  is  poorly  nourished.  Lips  of  fair  color.  Chest 
and  abdomen  are  negative. 

Rectal. — The  prostate  is  slightly  enlarged  on  the  left  side,  but  does  not 
bulge  into  the  rectum,  the  enlargement  being  chiefly  lateral.  The  right 
lobe  of  the  prostate  is  not  enlarged.  The  consistence  is  firm,  but  not  hard, 
not  tender.  The  left  seminal  vesicle  is  slightly  indurated,  the  right  is 
not. 

Urinalysis. — Acid.  Sp.  gr.  1010,  albumin  a  slight  cloud.  Microscopically, 
pus  cells  and  bacilli. 

Urethral. — There  is  a  tight  hard  stricture  3  cm.  distance  from  the 
meatus,  through  which  a  No.  19  F.  sound  passes  with  diflBculty,  but  after 
that  meets  no  obstruction.     Internal  urethrotomy  performed. 

May  30,  1904-—T'he  patient  has  been  treated  by  gradual  dilatation  with 
sounds.  There  is  still  considerable  induration  at  the  site  of  the  stricture 
but  a  No.  28  French  sound  will  pass. 

Cystoscopic  examination. — A  large  silver  catheter  passes  with  ease,  the 
bladder  is  large,  the  tonicity  good.  Retention  of  urine  complete.  The 
cystoscope  shows  a  definite  collar  of  hypertrophied  prostate  around  the 
entire  orifice  forming  a  circular  ring  which  is  most  evident  anteriorly. 
There  are  no  clefts  and  no  lobular  projections.  The  median  portion  of  the 
prostate  is  moderately  thickened  and  there  is  a  pouch  behind  it,  but  the 
ureters  can  be  seen  with  ease  and  are  apparently  normal.    The  bladder  is 


study  of  lJf5  Cases  of  •Perineal  Prostatectomy.  263 

considerably  trabeculated  with  numerous  pouches  and  several  definite 
diverticula.  With  finger  in  rectum  and  cystoscope  in  urethra  there  is  only 
slight  thickening  of  the  median  portion  made  out. 

October  4,  IDO-'i. — The  condition  of  the  patient  remains  the  same.  He 
can  void  very  little  naturally  and  uses  the  catheter  two  or  three  times  daily. 
Occasionally  he  suffers  considerably  from  cystitis.  He  has  not  had 
erections  for  a  long  time.  The  cystoscope  shows  a  circular  collar  of  slight 
but  definite  thickness  around  the  entire  orifice,  as  described  at  the  first 
cystoscopy.  Bottini  operation  would  be  probably  curative,  but  owing  to  the 
small  size  of  the  prostate  per  rectum,  it  would  probably  be  a  hazardous 
procedure.  Perineal  prostatectomy  was  therefore  advised.  He  has  been 
dilated  with  sounds  and  the  Kollmann  dilator  for  months  without  benefit. 
The  urethra  is  now  of  large  caliber,  but  there  is  still  considerable 
induration. 

Operation,  October  6,  1004- — Ether.  Perineal  prostatectomy  by  the  usual 
technique,  except  that  the  ejaculatory  bridge  was  divided  and  the  median 
portion  of  the  prostate  removed  suburethrally.  The  prostate  was  extremely 
small,  fibrous,  very  adherent  to  the  capsule  and  urethra.  The  median 
portion  was  so  intimately  adherent  and  so  fibrous  that  it  was  impossible 
to  remove  it  through  the  lateral  cavities,  and  in  view  of  the  absence  of 
sexual  powers  it  was  thought  advisable  to  excise  the  median  portion 
directly  through  the  ejaculatory  bridge  which  was  done  with  ease.  The 
amount  of  tissue  removed  was  small,  but  nothing  remained  except  the 
mucous  membrane  which  was  preserved.  The  wound  was  closed  as  usual 
with  double  tube  drainage  and  light  packs  for  the  lateral  cavities.  Patient 
stood  the  operation  well,  pulse  at  the  end  being  96.  Continuous  irrigation 
was  begun  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  after 
the  operation  was  99.6°  on  the  third  day  and  it  was  normal  after  the  fifth 
day.  The  tubes  were  removed  in  36  and  the  gauze  within  38  hours.  Urine 
began  to  come  through  the  urethra  on  the  fourth  day,  and  the  patient  was 
up  in  a  chair  on  the  eighth  day.  On  the  20th  day  the  condition  was  excel- 
lent, but  the  fistula  was  not  yet  healed.  On  the  next  day  epididymitis  be- 
gan on  the  right  side,  the  temperature  rose  to  102°.  The  swelling  went  on 
the  suppuration  and  had  to  be  opened  November  9,  considerable  pus  being 
evacuated.  Previous  to  this  the  patient  looked  very  sick,  his  temperature 
reached  102°  almost  every  day  and  on  November  9,  the  pulse  was  extremely 
weak,  160  to  the  minute  and  the  patient  was  drowsy.  After  evacuation 
of  the  pus  from  the  epididymis  the  patient  improved  steadily,  but  slowly, 
and  he  left  the  hospital  on  December  16,  1904.  The  perineal  fistula  was 
not  closed,  but  most  of  the  urine  passed  through  the  urethra.  He  had  not 
required  catheterization  since  the  operation.     There  was  no  incontinence. 

January  5,  190.5. — The  patient  voids  urine  naturally,  but  a  pin-point 
fistula  is  still  present  although  it  has  been  curetted  several  times.     The 


364  Hugh  II.  Young. 

urethra  has  been  dilated.  A  stricture  of  large  caliber  is  present,  but  a  No. 
28  sound  will  pass. 

Novemher  30,  1905. — Letter.  The  fistula  is  closed.  I  void  urine  natu- 
rally six  or  eight  times  during  the  day,  three  or  four  at  night,  about  one- 
quarter  of  a  pint  at  a  time.  I  have  a  slight  scalding  in  the  urethra  during 
urination.  I  have  no  erections  (they  were  absent  before  operation).  I 
have  had  no  treatment  and  my  general  health  is  excellent.  I  have  gained 
30  pounds  in  weight. 

February  8,  1906. — The  stricture  of  the  urethra  seems  to  be  coming  again. 
Following  your  request  I  passed  a  catheter  for  the  first  time  since  leaving 
the  hospital.  A  number  18  catheter  passed  with  difficulty  and  considerable 
pain  through  the  stricture.  There  were  about  four  ounces  of  residual  urine. 
I  void  from  one-fourth  to  one-half  a  pint  of  urine  at  a  time,  and  sometimes 
do  not  urinate  but  twice  during  the  night. 

The  patient  was  advised  to  dilate  the  stricture,  as  it  is  evident  that  this 
is  the  cause  of  the  imperfect  result. 

May  16,  1906. — Letter.  The  only  thing  that  I  can  complain  of  is  a  slight 
return  of  the  stricture,  but  I  have  not  passed  a  sound  or  a  catheter  since 
February.  I  void  urine  naturally  about  every  two  hours  in  the  day  time 
and  about  twice  at  night.  At  times  there  is  a  scalding  pain.  I  do  not 
have  erections.  I  have  had  no  treatment  since  the  operation.  My  general 
health  is  good,  and  I  have  gained  35  pounds  in  weight.  I  am  very  much 
Improved. 

Pathological  report. — The  specimen,  G.  U.  105,  consists  of  three  pieces, 
the  median  and  two  lateral  lobes,  and  weighs  in  all  G-4.  The  right  lobe 
measures  1.5  x  1.5  x  1  cm.  The  tissue  is  firm,  but  elastic,  and  on  section 
shows  considerable  fibrous  tissue,  but  some  evidence  of  glandular  tissue  is 
present.  The  left  lobe  measures  2  x  1.5  x  1  cm.,  weighs  G-2,  and  is  similar 
in  appearance  to  the  right.  The  median  bar  measures  1.7  x  .8  x  .5  cm.  and 
weighs  G-1.  A  small  area  of  urethral  mucosa  is  attached  to  it.  On  section 
it  seems  to  be  composed  largely  of  fibrous  tissue  The  lumina  of  the 
ejaculatory  ducts  are  seen  in  the  lower  portion. 

Microscopic  examination. — In  the  right  lobe  the  hypertrophy  is  a  mod- 
erately glandular  one,  the  acini  being  irregularly  distributed  through  the 
stroma  without  any  tendency  to  lobular  formation.  In  the  left  and  middle 
lobes  the  amount  of  the  adenomatous  tissue  is  considerably  less;  altogether 
there  is  more  gland  tissue  than  stroma.  The  acini  are  grouped  together 
in  areas,  the  lumina  at  times  being  fairly  regular,  at  other  times  showing 
marked  complexity.  There  is  considerable  young  connective  tissue  in  the 
stroma.  In  the  middle  bar  there  is  a  considerable  area  which  is  infiltrated 
with  some  leucocytes,  round  cells  and  numerous  polyblastic  cells  with  the 
formation  of  numerous  new  blood-vessels.  There  are  present  very  few 
acini  in  the  section  from  the  median  portion,  but  there  is  present  a  very 
considerable  interstitial  prostatitis. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  265 

Case  54. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Symptoms 
suggesting  stone.  None  found.  Cystoscopy  unsuccessful.  Cure  of  obstruc- 
tion.    Slight  burning  pain.    Followed  I4  months. 

No.  769.     S.  R.,  age  76,  widower,  admitted  October  4,  1904. 

Complaint. — "  Frequent  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  18  months  ago  with  nocturnal  frequency  of  urin- 
ation which  rapidly  increased  until  the  patient  had  to  arise  25  times  during 
the  night.  During  the  day  he  did  not  have  to  urinate  so  frequently,  only 
six  or  eight  times.  He  suffered  burning  pain  during  urination.  About  a 
year  ago  his  physician  began  the  use  of  a  catheter  and  vesical  irrigation, 
and  since  then  the  catheter  has  been  necessary  every  day,  but  he  has  al- 
ways been  able  to  void  a  small  amount.  Occasionally  he  has  had  pains  in 
the  right  side,  but  no  chills  or  fever.  His  general  health  has  been  good, 
but  he  has  suffered  very  greatly. 

S.  P. — The  bladder  is  small,  urination  difficult  and  painful,  and  the 
catheter  required  every  two  hours,  but  this  does  not  give  him  relief. 

Examination. — Patient  is  a  large  well  nourished  man  with  lips  of  good 
color.  The  heart  is  enlarged,  but  the  sounds  are  clear.  The  arteries  are 
sclerotic  and  the  abdomen  is  negative  except  in  the  lower  portion  where 
there  is  considerable  tenderness  over  the  bladder. 

Rectal. — The  prostate  is  moderately  hypertrophied,  rounded,  somewhat 
nodular  and  fairly  hard. 

Urinalysis. — Cloudy,  1020,  acid,  no  sugar,  a  trace  of  albumin.  Total 
amount  in  24  hours,  640  cc.     Total  urea  G-6.4. 

Cystoscopic. — A  soft  rubber  catheter  passes  with  ease.  The  urethral 
length  is  11  inches.  Very  little  urine  is  obtained.  The  bladder  capacity 
is  contracted,  being  only  200  cc.  It  is  irritable  and  instrumentation 
causes  great  pain.  Hemorrhage  is  produced  and  cystoscopy  is  therefore 
impossible. 

Preliminary  treatment. — Rubber  catheter  was  fastened  in  the  urethra 
and  urine  allowed  to  drain  continually  into  a  bottle.  The  patient  was 
instructed  to  drink  water  in  great  amount  and  was  given  purgatives 
and  urotropin.  After  four  days  the  patient's  condition  had  distinctly  im- 
proved, the  amount  of  urine  had  increased  daily  and  the  total  urea  was  22.4 
gr.     Total  amount  of  urine  2240  cc. 

Operation,  October  8,  IDOJf. — Spinal  cocainization.  Perineal  prostatectomy 
by  the  usual  technique.  One-third  of  a  grain  of  cocaine  was  injected  into 
the  spinal  canal  after  being  dissolved  in  the  spinal  fluid  drawn  out  into  the 
barrel  of  the  syringe.  The  lateral  lobes  were  enucleated  with  ease  and 
measured  3x4x5  cm.  in  size.  The  middle  lobe  was  then  caught  with 
the  tractor,  delivered  into  the  right  capsular  cavity  and  easily  enucleated. 
It  was  smooth,  globular,  2i/o  cm.  in  diameter.  The  wound  was  closed  as 
usual  with  double  catheter  drainage,  light  gauze  packs  for  the  lateral 
cavities.  The  pulse  before  the  operation  was  95,  the  blood  pressure  215. 
At  the  end  of  the  operation  the  pulse  was  105  and  the  blood  pressure  195. 


266  Hugh  H.  Young. 

As  soon  as  patient  was  removed  from  table  a  condition  of  collaiDse 
came  on,  pulse  imperceptible  at  wrist.  Blood  pressure  fell  to  80  and 
the  patient  became  unconscious.  An  intravenous  injection  of  500  cc. 
salt  solution  and  strychnine  .1  grains  was  given,  but  he  did  not  react  for 
about  half  an  hour  and  his  condition  at  one  time  seemed  desperate.  On 
return  to  ward  his  pulse  was  136,  and  he  was  still  slightly  irrational.  In 
the  evening  he  had  a  chill  and  a  temperature  of  101°  and  on  the  next  day 
a  temperature  of  102°;  after  that,  however,  his  temperature  fell  to  normal 
and  he  had  no  further  elevation,  and  the  convalescence  was  entirely 
satisfactory.  The  gauze  was  removed  on  the  day  after  the  operation  and 
the  tubes  on  the  next  day.  He  was  up  in  a  chair  on  the  seventh  day  in  good 
condition.  On  the  10th  day  he  was  walking  about  the  ward.  The  perineal 
fistula  closed  completely  on  the  18th  day,  and  the  patient  left  the  hospital 
on  the  28th  day.  His  condition  then  was  excellent,  and  the  wound  closed. 
He  was  able  to  retain  urine  four  hours  during  the  day,  but  voided  more 
frequently  during  the  night;  there  was  no  incontinence,  but  some  urgency 
of  urination.  Silver  catheter  passed  with  ease,  residual  urine  10  cc,  bladder 
capacity  320  cc.  Urine,  acid,  moderately  purulent.  Advised  to  take  uro- 
tropin,  water  in  abundance  and  to  dilate  bladder  by  retaining  his  urine  as 
long  as  possible. 

February  1,  1905. — During  the  day  I  void  urine  three  or  four  times  in  12 
hours  and  at  night  two  or  three  times  in  12  hours.  Urination  is  normal 
and  the  amount  voided  of  good  quantity.  I  have  no  pain  except  a  slight 
scalding.  Erections  have  not  returned.  (Absent  two  years  before  oper- 
ation. ) 

November  22.  1905. — I  have  slight  scalding  pain  when  voiding  urine, 
occasionally  it  is  acute.  While  I  am  still  or  sitting  I  feel  no  inconvenience, 
but  almost  the  moment  I  get  up  I  have  a  desire  to  urinate.  I  retire  at 
ten  o'clock  and  sleep  until  four,  when  I  awake  with  the  pain  spoken  of 
above. 

December  12,  1905. — I  have  had  no  treatment.  The  wound  has  remained 
closed.  I  void  urine  naturally  in  the  ordinary  amounts,  six  to  eight  times 
during  the  day  and  twice  at  night.  I  suffer  a  scalding  pain  when  the 
bladder  is  nearly  empty.  No  erections.  My  health  is  excellent  and  I  have 
gained  30  pounds. 

Pathological  report. — The  specimen,  G.  U.  107,  consists  of  the  three 
lobes  of  the  prostate  removed  in  four  pieces,  and  weighs  G-32.  The 
right  lobe  weighs  G-10,  and  measures  4.5x2.5x2  cm;  is  lobulated  and 
elastic.  There  is  considerable  peripheral  condensation  of  the  fibrous 
tissue.  The  cut  surface  shows  moderate  amount  of  dilated  ducts,  and 
only  a  small  amount  of  stroma.  The  left  lobe  weighs  G-18,  and  measures 
5x3.5x3  cm.  It  is  similar  in  character  to  the  right.  The  middle  lobe 
weighs  G-4,  and. measures  3x2.5x2  cm.  It  is  oval,  smooth,  encapsulated, 
and  on  section  shows  considerable  gland  tissue  and  numerous  dilated 
acini.    No  mucous  membrane,  no  ejaculatory  ducts,  no  calculus. 

Microscopic   examination. — The   hypertrophy    is    a   very   glandular   one. 


study  of  lJf5  Cases  of  'Perineal  Prosiaiedomy.  267 

the  gland  tissue  being  for  the  most  part  arranged  in  lobules.  In  many 
of  these  glandular  lobules  the  stroma  is  very  insignificant  in  amount,  and 
the  acini  are  rather  small,  only  an  occasional  dilated  one  being  seen.  There 
Is,  however,  very  marked  intraacinous  proliferation  and  numerous  papillo- 
matous projections  into  the  lumina  of  the  acini.  The  epithelium  lining 
the  acini  varies  a  great  deal,  at  times  consisting  of  two  layers,  an  internal 
very  high  columnar  and  an  external  more  cuboidal  type  of  cell.  At  other 
times  the  epithelium  is  many  layers  deep,  but  the  internal  layer  is 
nearly  always  of  the  high  columnar  type.  The  interspheroidal  tissue 
contains  comparatively  few  acini  and  these  are  compressed.  The  stroma 
consists  mostly  of  connective  tissue,  the  amount  of  smooth  muscle  being 
insignificant.  The  blood-vessels  show  practically  no  thickening  and  there 
is  very  little  prostatitis  present  in  the  sections  examined. 

Case  55. — Considerable  enlargement  of  median  and  lateral  lobes.  Drib- 
bling of  urine  for  seveii  years.    Cure.    Followed  six  months. 

No.  743.    A.  R.,  age  78,  admitted  October  9,  1904. 

On  invitation  of  Major  Arthur,  this  patient  was  operated  upon  at  the 
Soldiers'  Home  at  Washington. 

Complaint. — "  DiflBcult  and  frequent  urination  and  incontinence." 

Gonorrhoea  three  times  with  orchitis  on  left  side  during  the  last  attack. 

Present  illness  began  10  years  ago  with  difficulty  and  frequency  of 
urination,  especially  at  night.  After  that  the  size  of  the  stream  became 
progressively  smaller,  urination  more  difficult  and  frequent,  and  for  seven 
years  he  has  had  almost  constant  dribbling  of  urine.  No  complete  re- 
tention, no  hematuria,  burning  on  urination. 

S.  P. — There  is  almost  constant  dribbling  and  the  patient  has  to  void 
eight  or  ten  times  during  the  night. 

Examination. — The  patient  is  a  well  nourished  man.  Lungs,  heart,  and 
abdomen  are  negative. 

Rectal. — Prostate  is  considerably  enlarged,  smooth,  elastic. 

Urethral. — There  is  a  stricture  of  moderate  degree  about  4  cm.  from  the 
meatus. 

Vesical. — A  catheter  passes  with  ease  and  finds  95  cc.  residual  urine. 
(The  patient  has  been  catheterized  twice  daily  for  four  days,  and  from 
65  to  125  cc.  residual  urine  obtained.) 

Urinalysis. — Cloudy,  sp.  gr.  varied  from  1005  to  1013.  At  times  a'^id, 
at  others  alkaline.  There  is  a  trace  of  albumin,  no  sugar,  numerous  pus 
cells,  and  a  few  hyaline  casts.  The  total  quantity  varies  from  1100  to 
1600  cc.  daily. 

Operation.  October  9,  190Jf. — Spinal  anesthesia.  Perineal  prostatectomy 
by  the  usual  technique.  Two  fairly  large  lateral  lobes  were  easily  enucle- 
ated, the  urethra  being  torn.  The  median  bar  was  removed  by  the  sub- 
urethral method  after  intentional  division  across  the  ejaculatory  ducts. 
It  measured  2x2x3  cm.    No  mucous  membrane  was  removed. 

The  wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs 
for    the    lateral    cavities.      The    patient    stood    the    operation    well.      The 


268  Hugh  H.  Young. 

anesthesia  was  successful.  A  submammary  infusion  was  given  on  return 
to  room.  The  tubes  were  accidently  pulled  out  immediately  after  the 
operation  and  were  not  replaced. 

Convalescence. — The  patient  reacted  well.  The  temperature  remained 
normal  with  the  exception  of  an  elevation  to  100.8°  six  hours  after  the 
operation.  Urine  passed  through  the  anterior  urethra  nine  days  after  the 
operation,  and  on  the  16th  day  the  patient  voided  80  cc.  at  a  time  through 
the  anterior  urethra.  Epididymitis  developed  on  the  right  side  on  the  ITth 
day  and  led  to  abscess  formation  which  was  incised  on  the  22d  day. 

Xovember  23.  190 Jf. — Pin  point  fistula  persists,  but  at  times  there  is  no 
leakage  through  it.  Urination  is  still  frequent  and  is  associated  with 
burning.    He  voids  from  four  to  six  times  every  night. 

March  21,  1905. — The  patient  is  able  to  hold  urine  for  six  hours  without 
discomfort  during  the  day,  but  during  the  night  must  urinate  from  three 
to  six  times.  The  fistula  closes  at  times  for  three  days  and  then  opens 
again,  causing  him  considerable  discomfort. 

April  3,  1905. — The  patient  had  been  for  a  long  time  in  a  very  despondent 
frame  of  mind.  Yesterday  he  went  off  into  the  woods,  drank  carbolic 
acid  and  was  found  dead.  Post-mortem  examination  showed  the  bladder 
in  excellent  condition,  the  prostate  scarcely  perceptible,  and  a  very  small 
sinuous  urethral  fistula.  He  had  improved  immensely  and  was  steadily 
getting  better.    Letter  from  Major  Arthur. 

PatJiological  report. — The  specimen,  G.  U.  106,  consists  of  the  lateral  and 
median  portions  of  the  prostate  removed  each  in  one  piece.  The  lateral 
lobes  measure  about  2x2x4  cm.  and  present  the  typical  picture  of 
adenomatous  hjiDertrophy.  The  median  lobe  measures  2x2x3  cm.;  it  is 
similar  in  character  to  the  others.  No  mucous  membrane  is  attached.  The 
ejaculatory  ducts  are  not  seen. 

Microscopic  examination. — A  section  made  from  prostatic  tissue  re- 
moved at  autopsy  shows  a  lobulated  moderately  glandular  hyper- 
trophy. There  is  present  a  rather  marked  prostatitis  with  the 
formation  of  a  large  amount  of  interstitial  fibrous  tissue.  The 
acini  are  mostly  small  and  filled  with  proliferating  and  desqua- 
mated epithelial  cells  and  leucocytes.  At  times  the  acini  are  rather 
closely  aggregated,  but  at  other  times  they  are  separated  by  rather 
broad  bands  of  stroma.  The  primary  glandular  hypertrophy  in  this  case 
is  evidently  undergoing  considerable  change  as  a  result  of  inflammatory 
hyperplasia.     The  blood  vessels  show  a  considerable  degree  of  thickening. 

Case  56." — Considerable  enlargement  of  median  and  lateral  lobes.     Cure. 
Followed  tico  years. 
No.  472.    A.  R.,  age  61,  married,  admitted  October  11,  1903. 
Complaint. — "  Bladder  trouble." 
Gonorrhoea  six  times.     No  sequelae. 
Present  illness  began  about  nine  years  ago  with  slight  difficulty  at  the 

"  This  case  should  have  been  No.  16. 


study  of  145  Cases  of  Perineal  Prostatectomy. 


269 


beginning  of  urination.  Four  years  later  the  difficulty  had  become  con- 
siderable and  he  consulted  a  physician  who  passed  a  catheter  and  drew  off 
residual  urine.  Since  then  difficulty  and  frequency  of  urination  have  in- 
creased. Two  months  ago  patient  was  treated  several  times  by  urethral 
dilatation  with  sounds,  which  was  painful  and  produced  hemorrhage. 

/S.  P. — Urination  now  occurs  every  two  hours  during  the  day  and  six 
times  at  night.    He  suffers  no  pain  and  has  no  incontinence. 

Sexual  powers. — Erections  are  less  vigorous  than  formerly,  but  inter- 
course is  almost  normal. 

Examination. — The  patient  is  a  sturdy-looking  man,  lips  of  good  color. 
The  heart  is  enlarged,  but  the  sounds  are  clear.  The  lungs  and  abdomen 
are  negative. 


Fig.  43. — Long  pedunculated  median  lobe,  moderate  lateral  lobes. 


Rectal. — The  prostate  does  not  bulge  at  all  into  the  rectum,  the  posterior 
surface  is  flat  and  does  not  give  at  first  the  impression  of  being  hyper- 
trophied.  On  careful  examination,  however,  it  is  found  to  be  broader 
than  normal  and  it  is  impossible  to  find  any  upper  margin. 

Urinalysis. — Urine  cloudy,  acid,  1020,  considerable  albumin,  no  sugar. 
Urea  G-6  to  the  liter.  Microscopically,  pus  cells  very  numerous. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  200  cc.  residual 
urine.  The  cystoscope  shows  large  intravesical  hypertrophy  of  both  lateral 
lobes  with  a  deep  sulcus  between  them  and  on  each  side.  Behind  them 
is  a  middle  lobe  which  does  not  seem  to  be  very  large.  "With  finger  in 
rectum  and  cystoscope  in  urethra,  the  amount  of  tissue  did  not  seem  to  be 
greater  than  normal,  the  cystoscope  probably  lying  in  a  cleft. 


270  Eugli  H.  Young. 

Operation,  October  15,  1903. — Spinal  anesthesia.  Perineal  prostatectomy 
by  the  usual  technique.  One-fifth  of  a  grain  of  dry  sterile  cocaine  was 
dissolved  in  the  syringe  and  then  injected  into  the  spinal  canal.  The 
patient  was  immediately  put  on  the  table  and  the  anesthesia  was  perfect. 
The  lateral  lobes  were  considerably  enlarged  and  easily  enucleated.  The 
middle  lobe  was  removed  through  the  left  lateral  cavity  and  proved  to  be 
much  larger  than  was  expected,  being  about  2  cm.  in  diameter  and 
5  cm.  long  and  markedly  pedunculated  as  shown  in  Fig.  43.  The  urethra 
was  not  torn  and  the  ejaculatory  ducts  were  preserved.  A  small  tear 
was  made  in  the  vesical  mucosa.  The  wound  was  closed  as  usual  with 
double  tube  drainage  for  the  bladder  and  the  lateral  cavities  packed  with 
gauze.  The  patient  stood  the  operation  well.  His  pulse  at  the  end  was 
120.  Two  hours  later  he  had  a  severe  chill  and  his  temperature  arose  to 
103.2°.  Saline  infusion  of  salt  solution  was  given  immediately  after  return 
to  room  and  vesical  irrigation  was  begun. 

Convalescence. — The  gauze  was  removed  on  the  fourth  day  and  the 
tubes  on  the  fifth.  The  patient  was  in  a  chair  on  the  eighth  day.  The 
perineal  fistula  closed  on  the  18th  day.  The  patient  was  discharged  on  the 
25th  day.  At  that  time  he  was  able  to  retain  his  urine  for  three  hours 
and  he  was  free  from  pain.  There  was  slight  incontinence,  particularly 
after  coughing. 

May  22,  1904- — Letter.  I  urinate  about  every  four  hours,  do  not  get  up 
at  all  during  the  night  and  void  a  pint  in  the  morning.  Micturition  is 
normal.    Erections  have  not  returned. 

February  1,  1905. — I  void  urine  naturally  three  or  four  times  during 
the  day,  none  at  night.  Erections  have  returned  and  sexual  intercourse  is 
satisfactory  though  the  erections  are  not  perfect.    I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  40,  consists  of  three  pieces, 
two  lateral  lobes  measuring  each  about  5x3x2  cm.  and  a  middle  lobe 
4  X  3  X  1.5  cm.  in  size  as  shown  in  the  accompanying  photograph.  (Fig.  43.) 
The  total  weight  is  65  gr.,  the  middle  lobe  weighing  20  gr.  The  external 
surfaces  of  the  lobes  show  numerous  small  spheroids  more  or  less  loosely 
bound  together.  On  section  numerous  spheroids  containing  dilated  glands 
are  seen,  and  in  the  lateral  lobes  small  areas  of  greenish  yellow  pus  are 
seen. 

Microscopic  examination. — The  hypertrophy  is  a  distinctly  lobulated 
glandular  one.  The  acini  are  for  the  most  part  dilated  with  irregular 
complex  lumina.  Some  cystic  degeneration.  The  epithelium  lining  the 
acini  is  as  a  rule  two  layers  in  depth,  but  in  places  there  is  considerable 
cell  proliferation.  The  stroma  is  mostly  composed  of  fibrous  tissue,  and  the 
arteries  show  a  moderate  amount  of  thickening.  Some  areas  of  prostatitis 
are  present. 

Case  57. — Moderate  enlargement  of  median  and  lateral   lobes.     Cath- 
eter life  several  months.     Cure. 
No.  750.  J.  E.  C,  age  76,  widowed,  admitted  October  15,  1904. 
Complaint. — "  Prostatic   enlargement.     Catheter  ism." 


study  of  1J^5  Cases  of  'Perineal  Prostatectomy.  271 

Patient  never  had  gonorrhoea.  Ten  years  ago  the  patient  had  renal 
colic  on  the  left  side  and  passed  a  small  stone.  No  subsequent  attacks 
until  one  year  ago  when  he  had  typical  symptoms  of  renal  colic  on 
the  left  side  lasting  for  three  hours,  and  passed  a  calculus.  No  colic 
since. 

Present  illness  began  10  years  ago  with  a  slight  difficulty  in,  and  in- 
creased frequency  of  urination.  Since  then  there  has  been  a  gradual 
increase  in  the  symptoms.  Retention  of  urine  came  on  for  the  first 
time  14  months  ago,  and  he  was  then  catheterized  once  a  day  for  four 
weeks.  After  that  the  catheter  was  not  used  until  the  spring  of  1904, 
when  he  had  retention  of  urine  again.  For  several  months  he  has  been 
more  or  less  dependent  upon  the  catheter.  At  present  he  catheterizss 
himself  three  or  four  times  a  day,  finding  each  time  about  eight  ounces 
of  residual  urine.  He  is  able  to  void  only  small  amounts  of  urine.  He 
has  no  pain  except  when  the  bladder  becomes  full.  He  has  erections 
occasionally  and  once  in  a  while  has  a  nocturnal  emission.  Has  had 
no  sexual    intercourse   for   10   years.     His   general   health  is   excellent. 

Examination. — The  patient  is  a  sturdy  looking  man.  There  is  very 
slight  arteriosclerosis.     Heart,  lungs  and  abdomen  are  negative. 

Rectal  examination  shows  moderate  hypertrophy  of  the  prostate.  Me- 
dian furrow  and  notch  are  present.  The  prostate  is  round,  smooth, 
elastic,  and  firmer  in  the  right  than  in  the  left  lobe.  No  induration  in  the 
region  of  the  seminal  vesicles,  and  no  enlarged  glands  are  present.  The 
prostate  is  about  the  size  of  a  medium-sized  lemon.  The  urine  is  cloudy 
and  contains  a  slight  amount  of  albumin,  numerous  pus  and  epithelial 
cells  and  bacilli.     Sp.  gr.  1010. 

Gystoscopic  exavidnation. — A  coude  catheter  passes  easily  and  finds 
300  cc.  residual  urine.  The  bladder  capacity  is  350  cc.  The  tonicity  is 
good.  The  cystoscope  shows  a  small  median  lobe  with  a  sulcus  on  each 
side,  and  very  little  intravesical  hypertrophy  of  the  lateral  lobes.  The 
bladder  wall  is  markedly  trabeculated  and  numerous  small  pouches 
and  diverticula  are  seen,  especially  in  the  posterior  and  lateral  walls  of 
the  bladder.  The  ureters  cannot  be  seen,  being  behind  the  median  lobe. 
With  the  finger  in  the  rectum  and  cystoscope  in  the  urethra  the  amount 
of  tissue  in  the  median  portion  is  considerable,  and  it  is  impossible  to 
feel  the  beak  of  the  cystoscope. 

Operation,  October  2//,  190.'/. — Ether.  Perineal  prostatectomy  by  the 
usual  technique  with  the  exception  that  after  the  removal  of  the  two 
lateral  lobes  the  ejaculatory  bridge  was  intentionally  divided  trans- 
versely as  shown  in  Fig.  31,  and  the  median  lobe  of  the  prostate  re- 
moved. The  lateral  lobes  were  easily  enucleated,  the  right  being  larger 
than  the  left.  The  median  enlargement  came  away  in  three  pieces,  the 
last  a  sessile  intravesical  lobule  3  cm.  in  diameter.  Removal  of  this 
was  accomplished  with  a  finger  in  the  urethra  which  was  considerably 
lacerated.  There  was  very  little  hemorrhage  and  the  patient  stood  the 
operation  well.  The  wound  was  closed  as  usual  with  gauze  packing  for 
the  lateral  cavities  and  double  drainage  tubes  in  the  bladder.  Submam- 
mary infusion  was  given  on  the  table. 


272  Hugh  H.  Young. 

Convalescence. — The  patient  reacted  well.  The  gauze  was  removed  on 
the  third  day,  and  continuous  irrigation  was  kept  up  for  three  days  when 
the  tubes  were  removed.  The  patient  was  out  on  the  fifth  day  and  began 
to  walk  on  the  seventh.  Urine  began  to  flow  through  the  penis  on  the 
fifth  day  and  he  was  at  once  able  to  hold  it  for  two  hours.  There  was  no 
epididymitis  or  any  other  complication.  Temperature  for  three  days  after 
operation  reached   101.7°. 

Xovem'ber  12.  190^. — The  patient  voids  urine  about  every  three  hours, 
mostly  through  the  urethra,  but  a  small  amount  escapes  through  the 
fistula. 

•  November  15,  1904. — The  fistula  closed  on  the  19th  day.  (Closing  after 
the  use  of  the  gimlet  curette.)  The  patient  voided  urine  last  night  at 
1.30  o'clock  and  did  not  have  to  urinate  again  until  6.30  a.  m.  There  is 
no  incontinence.  Urine  flows  in  a  large  stream  and  without  pain.  Has 
had  no  instrumentation.  Discharged  from  hospital  on  the  22d  day.  No 
stricture,  no  residual  urine  present. 

January  18.  1905. — Letter.  I  very  seldom  urinate  during  the  night,  and 
urination  is  normal.    My  general  health  is  excellent. 

May  24,  1905. — The  urine  is  clear  and  passes  in  a  large  stream  at  in- 
tervals of  five  hours  during  the  day  and  eight  hours  at  night. 

November  20.  1905. — Letter.  I  am  happy  to  state  that  I  have  not  had 
a  single  day's  discomfort  from  my  urinary  organs  since  my  return  home. 
I  do  not  urinate  during  the  night.  Troubled  as  I  was  before  the  operation 
with  having  to  get  up  almost  every  hour  during  the  night,  and  urinating 
with  great  pain,  I  am  one  of  the  happiest  of  mortals.  I  have  occasional 
erections  at  night. 

November  30,  1905. — Letter.  Wound  has  remained  healed.  I  void  urine 
perfectly,  four  to  five  times  a  day  and  none  at  all  during  the  night,  often 
10  ounces  at  a  time.  I  suffer  no  pain,  have  erections  occasionally.  My 
general  health  is  excellent,  and  I  consider  myself  cured. 

May  7.  190G. — Letter.  I  urinate  at  intervals  of  five  or  six  hours  during 
the  day,  and  after  emptying  my  blad'der  at  bed  time  do  not  need  to  do  so 
again  until  six  or  seven  o'clock  the  next  morning.  The  passage  of  urine 
is  as  natural  as  when  a  boy.  I  have  erections  very  rarely.  Have  not 
attempted  intercourse.  There  have  been  no  complications  since  the 
operation  and  my  health  is  excellent. 

Pathological  report. — The  specimen,  G.  U.  Ill,  consists  of  three  pieces, 
right,  left,  and  median  lobes,  and  weighs  about  G-20,  the  lobes  being 
about  equal  in  size,  and  measuring  about  31^^  x  2%  x  2  cm.  Toward  the 
periphery  of  the  lobes  the  tissue  is  more  fibrous,  forming  a  fairly  definite 
capsule.  In  the  interior  numerous  dilated  glands  are  seen.  There  is  no 
Induration  or  suggestion  of  malignancy.  No  mucous  membrane  nor  ejacu- 
latory  ducts  were  removed. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with  some 
tendency  to  arrangement  in  lobules.  The  acini  are  for  the  most  part 
dilated,  but  do  not  show  the  complexity  of  lumina  which  one  sees  in  more 


study  of  1J^5  Cases  of  Perineal  Prostatectomy.  2T3 

glandular  prostates.  Here  and  there  cystic  dilatation  of  the  acini  with 
flattening  of  the  lining  epithelium  is  present.  The  epithelium  lining  the 
acini  is  usually  two  layers  thick,  the  superflcial  being  of  a  tall  cylindrical 
type  with  the  nucleus  near  the  base  of  the  cell,  while  the  layer  resting 
on  the  basement  membrane  is  more  cuboidal.  The  stroma  is  dense,  and 
mostly  composed  of  fibrous  tissue.  Some  prostatitis  is  present  in  areas. 
Numerous  corpora  amylacea  are  seen  in  the  ducts. 

Case  58. — Slight  enlargement  of  lateral  lobes.  Small  round  median  lobe. 
Small  suburethral  lobe.  Stricture  of  urethra.  Cured.  Followed  20 
months. 

No.  757.     A.  H.  C,  age  62,  married,  admitted  September  23,  1904. 

Complaint. — "  Bright's  disease." 

Gonorrhoea  at  the  age  of  21,  and  again  two  years  later. 

Present  illness  began  about  10  years  ago  with  slight  difficulty  in  urin- 
ation, which  continued  for  six  years  without  any  marked  increase  in 
frequency  of  urination.  During  the  past  year  he  has  had  to  urinate  four 
times  during  the  night  and  about  10  times  during  the  day.  Micturition 
is  accompanied  by  considerable  straining  and  at  times  there  is  inconti- 
nence both  night  and  day.  Has  never  had  complete  retention  of  urine  nor 
has  he  been  catheterized. 

Sexual  potcers. — Erections  are  still  present,  but  the  desire  is  practically 
nil  and  ejaculation  is  painful. 

Examination. — The  patient  is  a  well  nourished  man.  Lips  and  mucous 
membranes  of  good  color.     Heart,  lungs,  and  abdomen  negative. 

Rectal  examination. — The  prostate  is  slightly  enlarged  in  both  lateral 
lobes,  soft  and  smooth.  The  seminal  vesicles  are  not  indurated.  Slight 
urethral  discharge  is  present  which  shows  microscopically  a  few  intra- 
cellular diplococci,  which  are  not  gonococci.  Examination  of  the  urethra 
with  bougies-a-boule  shows  a  stricture  of  moderately  small  caliber  at  the 
penoscrotal  juncture.  The  urine  is  cloudy  in  all  three  glasses  and  contains 
considerable  amount  of  pus,  but  no  bacteria.  Sp.  gr.  1020,  acid,  albumin  a 
trace.    Urea  8  gr.  to  the  liter. 

October  20.' — The  patient  has  been  treated  by  gradual  dilatation  of  the 
urethral  stricture.  The  stricture  has  dilated  easily.  Filiforms  and  follow- 
ers were  used  at  first,  but  after  three  weeks  a  No.  26  sound  could  be  passed 
with  ease.  The  urine  has  improved  remarkably,  and  is  now  clear  except 
for  a  few  shreds.  The  patient  still  voids  urine  four  or  five  times  at  night, 
and  a  catheter  finds  210  cc.  residual  urine. 

Cystoscopic  examination.- — A  catheter  passes  with  ease,  finds  210  cc. 
residual  urine,  and  a  bladder  capacity  of  400  cc.  and  excellent  vesical 
tonicity.  The  cystoscope  shows  a  fairly  large  sessile  median  lobe  with  a 
sulcus  on  each  side.  The  lateral  lobes  project  very  little  into  the  bladder, 
which  is  considerably  trabeculated,  hypergemic  but  not  inflamed.  There  is 
no  foreign  body  present.  On  the  floor  of  the  bladder  is  a  prominent  trans- 
verse ridge  separating  two  deep  pouches.     The  ureters  cannot  be  seen. 


274       ■  Hugh  H.  Young. 

Operation,  October  2^,  190^. — Perineal  prostatectomy  by  the  usual  tech- 
nique. The  lateral  lobes  which  were  only  slightly  hypertrophied  were 
easily  enucleated.  The  median  lobe  could  not  be  engaged  with  the  tractor, 
and  when  the  finger  was  introduced  the  lobe  was  found  to  be  pedunculated 
in  character.  The  finger  was  also  ineffectual  in  drawing  the  lobe  into  one 
of  the  lateral  cavities  so  that  it  was  necessary  to  use  a  curved  forceps 
which  was  inserted  through  the  urethra  and  made  to  grapple  the  lobe 
which  was  then  drawn  into  the  urethra.  While  held  in  this  position  its 
right  lateral  border  was  exposed  by  blunt  dissection  through  the  right 
lateral  cavity,  and  it  was  finally  enucleated  without  removing  any  of  the 
mucous  membrane.  Examination  then  showed  a  small  rounded  subure- 
thral lobule  which  was  also  enucleated.  The  ejaculatory  ducts  were  pre- 
served and  only  two  small  rents  were  made  in  the  urethra.  The  wound 
was  closed  as  usual  with  double  tube  drainage  in  the  bladder  and  light 
gauze  packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well, 
the  pulse  being  90  at  the  end.  An  infusion  and  continuous  intravesical 
irrigation  were  instituted  on  return  of  patient  to  the  ward. 

Convalescence. — On  the  day  after  the  operation  the  temperature  rose  to 
101°,  but  was  practically  normal  on  the  next  day,  and  did  not  rise  again. 
The  gauze  and  tubes  were  removed  on  the  third  day,  and  interval  urin- 
ation was  established  at  once.  On  the  fourth  day  most  of  the  urine  came 
through  the  penis.  The  patient  was  out  of  bed  on  the  fifth  day  and  began 
walking  on  the  sixth,  on  which  day  the  perineal  fistula  healed.  He  had 
no  complications  of  any  sort  and  was  discharged  on  the  18th  day.  At  that 
time  he  could  hold  his  urine  for  six  hours.  The  perineal  wound  had  been 
closed  for  12  days,  he  had  perfect  control,  and  his  general  health  was  ex- 
cellent. 

Examination,  October  12. — The  perineal  wound  is  closed,  urine  is  voided 
in  a  good  stream,  silver  catheter  passes  with  ease,  and  there  is  no  residual 
urine  present.  Urine  is  cloudy  and  contains  pus  and  the  patient  has  a 
slight  urethral  discharge.  He  is  advised  to  take  irrigations  of  bichloride 
of  mercury  until  this  ceases. 

February  1,  1905. — Letter.  I  void  naturally  three  to  five  times  during 
the  day,  and  once  at  night.  There  is  no  fistula  and  I  consider  myself  cured. 
Erections  have  returned  and  I  have  intercourse. 

November  30,  1905. — Letter.  I  void  urine  naturally  and  arise  only  once 
at  night.  I  have  erections  but  intercourse  is  not  very  satisfactory.  My 
general  health  is  splendid,  I  have  gained  20  pounds  and  I  consider  myself 
cured. 

May  15,  1906. — Letter.  I  void  urine  normally  and  at  normal  intervals, 
about  half  a  pint  at  a  time.  I  have  very  little  pain.  Erections  and  sexual 
intercourse  are  satisfactory.  I  have  had  no  complications  or  treatment 
since  operation.  I  have  gained  about  30  pounds,  and  I  feel  that  I  am 
cured. 

Pathological  report. — The  specimen,  G.  U.  112,  consists  of  the  three  lobes 
of  the  prostate  each  removed  in  one  piece,  and  weighs  G-27.     The  right 


study  of  IJ^o  Cases  of  'Perineal  Prostatectomy.  275 

lateral  lobe  is  the  larger,  weighs  G-13  and  measures  4.5  x  3  x  2  cm.  Its 
upper  vesical  portion  is  smooth  and  regularly  rounded  forming  a  definite 
lobe  separated  from  the  lower  lobulated  portions.  On  section  the  fibrous 
capsule  is  unusually  well  marked  and  strips  off  the  prostate  with  ease. 
The  upper  portion  is  a  distinct  round  lobe  2.5  cm.  in  diameter.  In  its 
central  portion  there  is  a  small  hemorrhagic  area  with  yellowish  specks 
in  a  grayish  field,  and  slightly  suggestive  of  malignancy.  The  outer  portion 
of  this  lobule  is  quite  fibrous.  A  moderate  number  of  dilated  glands  are 
present.  The  left  lobe  measures  3x2x2  cm.  in  size,  is  irregular  and 
shows  considerable  fibrous  stroma.  The  median  lobe  is  about  2.5  x  2  x  1.2 
cm.  in  size  and  similar  in  character  to  the  left.  No  ejaculatory  ducts,  no 
calculus.  A  small  bit  of  mucous  membrane  has  been  removed  with  the 
median  lobe. 

Microscopic  examination. — A  section  from  the  hemorrhagic  area  in  the 
right  lateral  lobe  presents  a  very  interesting  picture.  There  is  a  great  in- 
crease in  the  fibrous  tissue  with  some  increase  in  the  muscle  fibers,  and  a 
comparatively  small  number  of  acini.  The  great  majority  of  the  acini  are 
small  and  apparently  compressed,  and  in  areas  there  is  almost  complete 
destruction  of  the  acini.  In  sections  from  other  portions,  about  many  of 
the  acini  there  is  a  rather  dense  layer  of  connective  tissue  forming  almost 
a  thickened  basement  membrane,  and  outside  this  tissue  of  apparently  re- 
cent formation  the  interstitial  fibrous  hyperplasia  is  quite  marked,  often 
assuming  a  concentric  arrangement  about  the  acini.  There  are  a  few 
small  areas  of  round  celled  infiltration  and  an  occasional  leucocyte.  The 
epithelium  lining  the  tubules,  in  many  areas  almost  fills  the  lumen.  In 
a  few  dilated  acini,  which  are  present  in  the  section,  the  epithelium  is 
distinctly  flattened.  There  is  considerable  general  increase  in  the  smooth 
.  muscle,  in  some  areas  myomatous  tissue  being  rather  abundant,  while  in 
other  areas  the  fibrous  tissue  predominates. 

The  section  is  that  of  fibro-myomatous  hypertrophy  with  partial  atrophy 
of  the  adenomatous  tissue. 

Case  59. — Slight  enlargement  of  median  and  lateral  lohules.  Contracted 
'bladder;  frequent  urination.     Cure.    Followed  19  months. 

No  756.     A.  W.,  age  65,  single,  admitted  October  15,  1904. 

Complaint. — "  Frequency  of  urination." 

Had  gonorrhoea  at  the  age  of  25  and  again  10  years  later. 

Present  illness  began  four  years  ago  with  difficulty  of  urination.  During 
the  next  year  difficulty  and  frequency  increased  and  three  years  ago  he 
had  complete  retention  and  had  to  be  catheterized.  Since  then  has  required 
catheterization  several  times.  Has  suffered  no  pain,  and  has  not  lost 
weight. 

8.  P. — Urination  about  every  two  hours,  and  often  very  difficult.  Occa- 
sionally very  great  frequency.    No  incontinence,  no  pain. 

Sexual  powers. — Erections  are  still  present,  has  not  had  intercourse  for 
two  years. 


276  Hugh  H.  Young. 

Examination. — The  patient  is  a  sturdy  looking  man,  lips  of  good  color, 
slight  arteriosclerosis,  pulse  of  good  volume.  A  systolic  murmur  is 
present  at  apex.     Abdomen,  negative. 

Genitalia. — The  right  testicle  is  undescended  but  is  palpable  in  the 
inguinal  canal. 

Rectal. — A  large  excoriated  pile  is  present.  The  prostate  is  moderately 
enlarged,  bulges  considerably  into  the  rectum,  the  median  furrow  is  shallow 
and  the  notch  is  absent.  It  is  smooth,  elastic,  but  firm.  There  are  no 
nodules,  no  induration  and  the  seminal  vesicles  are  negative. 

Cystoscopic. — Coude  catheter  passes  with  ease  and  finds  30  cc.  residual 
urine.  The  bladder  capacity  is  150  cc.  It  is  very  irritable,  and  after  being 
filled  several  times  it  will  retain  only  100  cc.  The  cystoscope  shows  a 
small  rounded  median  lobe  with  a  fairly  deep  sulcus  on  either  side;  lateral 
lobes  are  not  intravesically  hypertrophied.  The  bladder  is  considerably 
trabeculated;  tnere  is  no  stone  present.  With  finger  in  rectum  and  cysto- 
scope in  urethra  the  beak  cannot  be  felt  and  the  thickness  of  the  median 
portion  is  considerably  increased. 

Urinalysis. — Slightly  cloudy,  acid,  sp.  gr.  1015,  no  albumin,  no  sugar. 
Urea  G-17  in  24  hours.     Microscopically,  pus  cells  and  colon  bacilli. 

October  20,  1904- — The  patient  returns  two  days  after  cystoscopy.  Urin- 
ation has  been  every  half  hour  except  when  he  has  used  a  catheter,  after 
which  he  has  relief  for  two  hours. 

October  22,  1904- — Urination  still  diflBcult  and  frequent.  Catheter  finds 
only  a  few  drops  of  residual  urine,  and  bladder  capacity  is  very  small. 

Operation,  October  25,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Enucleation  of  slightly  enlarged  lateral  lobes,  and  a 
small  median  lobe. 

The  lateral  lobes  were  only  moderately  hypertrophied.  The  median 
lobe  measured  3x2x2  cm.  in  size  and  was  easily  removed  through  one 
of  the  lateral  cavities.     The  ejacuatory  ducts  were  preserved. 

The  wound  was  closed  as  usual.  Double  drainage  tubes  in  the  bladder 
and  light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation 
well,  the  pulse  at  the  end  being  80.  Continuous  irrigation  and  infusion 
on  return  to  the  ward. 

Convalescence. — The  patient  convalesced  well,  the  highest  temperature 
being  99.8°  on  the  day  after  the  operation,  after  which  it  was  practically 
normal.  The  tubes  and  gauze  were  removed  on  the  second  day,  and  the 
patient  was  up  before  the  end  of  a  week.  On  November  3,  a  note  was  made 
that  the  patient's  condition  was  excellent,  wound  healthy,  and  urine  com- 
ing partly  through  the  anterior  urethra.  He  had  had  no  rise  in  tempera- 
ture, which  was  normal,  and  his  pulse  since  the  operation  had  ranged  be- 
tween 70  and  85.    He  slept  seven  hours  at  a  time  and  enjoyed  his  meals. 

November  7,  1904- — Two  days  ago  the  patient  began  to  vomit.  Before 
this  his  bowels  had  not  moved  for  several  days.  The  pulse  has  been  good, 
varying  from  80  to  96  and  the  patient  has  voided  urine  in  good  amount 
through  the  urethra.     Urine  contains  no  albumin,  no  casts,  sp.  gr.  1022. 


study  of  1J/.0  Cases  of  'Perineal  Prostatectomy.  277 

He  was  infused,  put  on  nutritive  enemata  and  active  hydrotherapy.  The 
nausea  and  vomiting  still  persist. 

November  9,  1904- — The  patient  has  ceased  vomiting  and  he  is  more 
comfortable. 

November  18,  1904- — The  convalescence  was  considerably  retarded  by  the 
attack  of  nausea  and  vomiting.  Perineal  fistula  has  closed.  The  patient 
voids  urine  in  a  good  stream  at  intervals  of  two  to  four  hours  and  in  large 
amounts.  His  cardiac  murmur  is  much  more  pronounced  since  attack  of 
nausea.    Patient  discharged  24th  day. 

May  1,  1905. —  (Five  months  after  operation.)  Urination  is  normal;  the 
stream  large;  interval  five  hours.  Sexual  desire  and  partial  erections 
have  returned.    Urine  is  clear  and  contains  no  pus. 

November  30,  1905. — I  void  urine  naturally  twice  during  the  day  and 
twice  during  the  night.  The  wound  is  closed,  I  have  no  pain  and  am 
cured.    I  have  erections,  but  have  not  attempted  intercourse. 

May  8,  1906. — Patient  comes  for  examination.  He  says  that  he  voids 
urine  naturally  and  with  ease.  Does  not  have  to  arise  during  the  night. 
He  suffers  no  pain.  He  has  erections  occasionally.  General  health  ex- 
cellent and  he  considers  himself  entirely  cured.  The  patient  voided  about 
150  cc.  urine,  clear  and  microscopically  negative.  Rectal  examination 
negative.  Silver  catheter  passes  with  ease,  and  shows  no  residual  urine, 
no  stricture. 

Pathological  report. — The  specimen,  G.  U.  109,  consists  of  the  three  lobes 
of  the  prostate  and  weighs  G-13.  The  right  lobe  weighs  2.5  x  1.5  x  1  cm.  and 
weighs  G-3.  The  left  lobe  measures  3  x  1.5  x  1  cm.  and  weighs  G-7.  The 
middle  lobe  2x2x1  cm.  and  weighs  G-3.  The  surfaces  are  irregularly 
lobulated,  and  the  sections  show  numerous  spheroids,  and  dilated  acini. 
Towards  the  periphery  there  is  considerable  fibrous  tissue. 

Microscopic  examination. — In  the  left  lobe  the  hypertrophy  is  a  moder- 
ately glandular  one  with  considerable  dilatation  and  occasional  cystic 
degeneration  of  the  acini.  In  the  right  and  middle  lobes  the  hypertrophy 
tends  distinctly  towards  the  fibro-muscular  form,  the  stroma  being  some- 
what in  excess.  There  are  however  areas  which  present  the  usual  picture 
of  a  glandular  hypertrophy.  The  stroma  throughout  the  whole  gland  is 
comparatively  dense,  and  contains  much  more  connective  tissue  than 
muscle.  The  stroma  in  the  portions  where  the  acini  are  numerous  shows 
considerable  new  connective  tissue  formation.  Some  areas  of  chronic 
interstitial  and  glandular  prostatitis  are  present. 

Case  60. — 'Small  round  median  lobe.  Moderate  lateral  lobes.  Com- 
plete retention.    Cure.    Followed  eighteen  months. 

No.  772.     F.  A.  G.,  age  71,  married,  admitted  October  1,  1904. 

Complaint. — "  Enlarged  prostate." 

Had  gonorrhoea  in   his   youth.     No   complications. 

Present  illness  began  18  months  ago  with  slight  frequency  of  urina- 
tion which  gradually  increased  until  recently  the  patient  was  urinating 
five   times   during  the  night.     The   stream  was  small,   lacked   force,   but 

Vol.  XIV.— 19. 


278  Hugh  H.  Young. 

there  was  never  any  pain  nor  dribbling.  There  was  no  hesitation,  but 
often  considerable  precipitancy.  About  10  days  ago  retention  of  urine 
became  complete  and  since  then  the  patient  has  been  unable  to  void  and 
has  required  catheterization  daily.  His  sexual  powers  have  been  absent 
for  five  years. 

Examination. — The  patient  is  a  well-nourished  man  with  lips  of  good 
color.     Chest  and  abdomen  are  negative. 

Reptal. — The  prostate  is  moderately  enlarged,  smooth  and  fairly  soft. 
The  seminal  vesicles  are  negative.  Urine  is  acid  and  contains  pus  cells 
and  bacilli,  and  there  is  no  evidence  of  renal  insufficiency. 

Operation,  October  28,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  of  moderate  size  and  neither  the 
mucous  membrane  of  the  urethra  nor  the  bladder  was  torn  in  their  re- 
moval. The  median  lobe  was  then  drawn  with  the  tractor  into  the  left 
lateral  cavity  where  it  was  enucleated  with  some  difficulty  owing  to  close 
adhesions,  but  the  mucous  membrane  covering"  it  was  not  torn.  This  lobe 
was  globular  and  measured  1%  cm.  in  diameter.  The  finger  was  then 
inserted  into  the  bladder  through  the  urethra  and  no  prostatic  enlarge- 
ment detected.  The  wound  was  closed  as  usual  with  double  drainage 
tubes  and  light  packs  for  the  lateral  cavities.  Infusion  and  continuous 
irrigation  on  return  to  room.  The  condition  of  the  patient  was  excel- 
lent at  the  end  of  the  operation. 

Convalescence. — 'The  patient  reacted  well.  The  gauze  was  removed 
on  the  second  day  and  the  tubes  on  the  third.  The  patient  was  out  of 
bed  on  the  eighth  day  and  the  fistula  closed  within  two  weeks.  There 
were  no  complications  except  considerable  bronchitis  and  slight  fever 
for  10  days.     He  left  the  hospital  on  the  31st  day. 

yfanuary  10,  1905. — 'The  patient  says  he  feels  better  now  than  he  has 
for  years.  Only  gets  up  once  at  night  to^  urinate  and  can  retain  urine 
six  or  eight  hours  in  the  day.  He  voids  with  a  good  stream  without 
hesitation  and  has  no  incontinence.  A  catheter  passes  without  meeting 
obstruction  and  finds  no  residual  urine  present.  The  bladder  capacity  is 
400  cc.     The  urine  is  purulent  and  contains  bacilli. 

Septenfiber  22,  1905. — 'The  patient  has  been  laid  up  with  epididymitis 
on  the  right  side.     Urination  is  normal. 

December  22,  1905.— ^The  right  testicle  has  again  become  swollen  and 
the  patient  has  suffered  considerable  pain.  Urine  is  voided  in  a  large 
stream  three  or  four  times  during  the  day  and  only  once  at  night.  The 
wound  is  healed  and  the  patient  suffers  no  pain.  Erections  which  were 
absent  before  operation  have  not  returned.  The  urine  still  contains  pus 
and  bacilli. 

May  9,  1906. — I  void  urine  naturally,  three  or  four  times  during  the 
day  and  often  not  at  all  during  the  night,  about  eight  ounces  at  a  time 
without  pain.  Erections  which  were  absent  for  several  years  have  not 
returned.     My  general  health  is  excellent  and   I   consider  myself  cured. 

Pathological  report. — iThe  specimen,  G.  U.  114,  consists  of  the  three 
lobes  of  the  prostate  each  removed  in  one  piece  and  weighs  28  gm.     The 


study  of  145  Cases  of  ■Perineal  Prostaiectomy.  279 

right  lobe  weighs  10  gm.,  and  measures  4  x  2  x  1.5  cm.  It  is  soft,  elas- 
tic, fairly  smooth,  and  on  section  shows  spheroids  with  numerous  dilated 
ducts,  and  a  moderate  amount  of  stroma.  The  left  lobe  weighs  10  gm., 
measures  3.5  x  2  x  1.5  cm.,  and  is  similar  in  appearance  to  the  right,  but 
shows  more  cystic  dilatation,  and  in  places  greenish  secretion  suggesting 
pus.  The  median  lobe  weighs  8  gm.,  and  shows  more  fibrous  tissue 
than  the  lateral  lobes.  No  mucous  membrane,  no  ejaculatory  ducts,  no 
calculi. 

Microscopic  examination. — The  hypertrophy  in  the  right  and  left  lobes 
is  of  the  glandular  type  with  dilatation  of  the  ducts  and  in  places  quite 
a  marked  cystic  degeneration.  The  stroma  is  comparatively  small  in 
amount  and  contains  more  fibrous  than  muscle  tissue.  There  is  consid- 
erable interstitial  and  glandular  prostatitis. 

The  median  lobe  contains  adenomatous  areas  in  which  the  acini  are 
dilated,  but  the  stroma  is  far  in  excess.  It  is  a  fibro-muscular  type  of 
hypertrophy  with  the  fibrous  element  predominating,  and  some  points  of 
round  celled  and  polynuclear   infiltration. 

Case  61. — Moderate  hypertrophy  of  median  and  lateral  lohes.  Acute 
cystitis  and  epididymitis  preceding  operation.  Cure.  Followed  18 
months. 

No.  831.     C.  W.  P.,  age  50,  married,  admitted  November  11,  1904. 

Complaint. — "  Frequency  of  urination  and  burning." 

Gonorrhoea  25  and  23  years  ago  with  apparently  no  symptoms  of  pos- 
terior  involvement. 

Present  illness  began  eight  years  ago  with  difficulty  in  starting  uri- 
nation. The  patient  consulted  a  physician  who  passed  sounds,  but  found 
no  stricture  and  diagnosed  enlargement  of  the  prostate.  From  that  time 
until  now  his  condition  has  grown  gradually  worse.  On  November  5 
he  had  complete  retention  of  urine  for  the  first  time  and  since  then 
has  been  catheterized  six  times  on  this  account.  Since  then  both  tes- 
ticles  have   become   swollen   and   very   painful. 

8.  P. — Urination  about  every  hour  during  the  day  and  10  times  at 
night.     Very   little   pain,   no   hemorrhage.     General   health   excellent. 

Sexual  powers. — No  note   made.  , 

Examination. — Patient  is  a  well-nourished  man  with  lips  of  good  color. 
The  chest  and  abdomen  are  negative. 

Genitalia. — 'Both  epididymes  are  slightly  swollen,  indurated  and  very 
tender,  the  result  of  recent  epididymitis. 

Rectal. — The  prostate  is  moderately  enlarged,  smooth,  elastic.  The 
seminal   vesicles    are   negative. 

Cystoscopic. — Owing  to  the  presence  of  epididymitis  cystoscopy  was 
not  performed.  A  large  silver  catheter  passes  with  ease  and  finds  120  cc. 
residual  urine.  The  bladder  is  irritable,  acutely  inflamed,  and  catheter- 
ization is  painful.  Owing  to  the  epididymitis  it  was  thought  advisable 
to  postpone  the  operation,  but  the  frequent  and  dfflcult  urination  and 
pain   on   catheterization   rendered   immediate   operation   advisable. 


280  Hugh  H.  Young. 

Urinalysis. — Urine  cloudy,  acid,  1015,  no  sugar,  albumin  a  trace.  Large 
amount  of  pus  and  mucus  present. 

Operation,  November  12,  IDOJ/. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  easily  enucleated  and  were  only 
moderately  enlarged.  The  median  portion  came  away  in  two  pieces,  one 
a  small  median  bar,  and  the  other  an  intravesical  lobule  which  was  re- 
moved through  the  left  lateral  cavity.  The  ejaculatory  ducts  were  pre- 
served intact  and  only  a  small  tear  was  made  in  the  urethra  along  its 
left  lateral  wall.  The  wound  was  closed  as  usual  with  double  tube 
drainage  for  the  bladder,  and  light  packs  for  the  lateral  cavities.  The 
patient  stood  the  operation  well.  Pulse  at  the  end  100.  Infusion  and 
irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well,  but  had  a  chill  on  the  day 
after  the  operation  and  a  rise  of  temperature  to  104.5°.  After  that  the 
temperature  ranged  between  99°  and  101°  until  the  seventh  day  when 
it  rose  to  102°,  and  was  associated  with  an  increase  in  the  inflammation 
in  the  epididymes.  After  that  the  left  epididymis  returned  to  normal, 
but  the  right  went  on  to  suppuration  and  on  December  15,  33  days  after 
the  operation,  the  abscess  was  opened  through  two  incisions.  After 
that  the  patient  rapidly  improved  and  was  discharged  six  days  later 
in  excellent  condition.  The  gauze  and  tubes  were  removed  at  the  end 
of  24  hours.  The  urine  was  very  slow  in  passing  through  the  urethra, 
and  the  perineal  fistula  was  still  open  on  his  discharge  from  the  hos- 
pital on  the  39th  day.  He  was  voiding  urine,  however,  at  intervals  of 
three  or  four  hours,  had  no  pain  in  the  bladder,  and  the  right  epididy- 
mis was  markedly  improved. 

May  8,  1906. — Letter.  I  void  urine  naturally  about  five  times  in  24 
hours,  sometimes  not  at  all  during  the  night.  The  amount  voided  at 
one  time  is  about  10  ounces.  I  suffer  no  pain,  erections  have  returned 
and  I  have  satisfactory  intercourse.  My  general  health  is  good,  I  have 
gained  10  pounds  in  weight,  and  I  consider  mysef  cured. 

Pathological  report. — Specimen,  G.  U.  118.  The  prostate  has  been 
removed  in  four  pieces,  and  weighs  14  gm.  The  right,  left  and  median 
portions  of  the  prostate  are  about  equal  in  size,  measuring  each  about 
2.5  X  2  X  1.5  cm.  A  small  irregular  intravesical  median  lobe  has  been 
removed  in  one  piece  and  measures  1.5  x  1  x  1  cm.  The  surface  of  the 
lobes  is  irregular  and  somewhat  torn,  rather  soft  in  consistence,  and 
on  section  presents  no  spheroids. 

Microscopic  examination. — 'The  hypertrophy  is  of  the  distinctly  gland- 
ular type  and  arranged  in  lobules.  There  is  present  quite  a  marked 
glandular  and  interstitial  prostatitis,  and  the  lumina  of  the  acini  are 
in  many  areas  filled  with  degenerated  epithelial  cells  and  leucocytes. 
The  stroma  is  largely  composed  of  fibrous  tissue  and  there  has  been 
formed  considerable  new  inflammatory  tissue  interlacing  in  different 
directions.     The   arteries   show   no   thickening. 


study  of  lJf5  Cases  of  'Perineal  Prostatectomy.  281 

Case  62. — Moderate  hypertrophy  of  median  and  lateral  lodes.  Two 
vesical   calculi.     Cure.     Followed  18   months. 

No.  786.     E.  S.,  age  68,  single,  admitted  November  5,  1904. 

Complaint. — <"  Painful   and    frequent    urination." 

Patient  had  gonorrhoea  in  his  youth. 

Present  illness  began  three  years  ago  with  sudden  retention  of  urine 
after  drinking  beer.  After  this  he  had  to  be  catheterized  for  several 
months.  Since  then  he  has  not  required  the  catheter,  but  micturition  has 
been  very  frequent  and  painful. 

S.  P. — -The  patient  urinates  every  half  hour  night  and  day.  Mic- 
turition is  accompanied  by  a  severe  pain  which  radiates  to  the  end  of 
the   penis. 

Sexual  powers. — »Patient  has  erections,  but  has  not  had  intercourse 
for  several  years.  His  general  health  is  bad  and  he  has  lost  about  60 
pounds  in  weight  in  the  past  five  months. 

Examination. — 'The  patient  is  rather  slender,  and  his  lips  are  pale. 
Chest  and   abdomen   are   negative. 

Genitalia.— '■Max^.e^  thickening  of  both  epididymes.  No  evidence  of 
hernia.     Arteries   somewhat  sclerotic,  but   pulse  regular   and  full. 

Rectal. — The  prostate  is  moderately  hypertrophied,  the  left  lobe  being 
the  more  prominent.  The  median  furrow  and  notch  are  obliterated,  and 
the  contour  is  rounded,  smooth  and  elastic.  The  seminal  vesicles  are  not 
palpable. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1025,  no  sugar,  a  trace  of  albumin, 
much  pus,  but  no  casts. 

Cystoscopic  examination. — A  catheter  passes  with  ease  and  finds  140 
cc.  residual  urine  (at  other  times  from  350  to  440  cc.  residual  were 
found).  The  bladder  is  very  irritable,  and  the  tonicity  good.  The  cysto- 
scope  shows  two  fairly  large  calculi  in  the  base  of  the  bladder,  dark 
brown  in  color  and  with  irregular  surfaces.  The  bladder  is  consider- 
ably infiamed  and  trabeculated,  but  no  diverticula  are  seen.  The  in- 
travesical portion  of  the  prostate  is  only  slightly  enlarged,  but  irregular 
in  shape.  The  left  lateral  lobe  is  only  slightly  hypertrophied,  the  right 
is  more  prominent,  and  connecting  the  two  is  an  irregular  median  bar 
of  moderate  degree.  With  finger  in  rectum  and  cystoscope  in  urethra 
it  is  impossible  to  feel  the  beak  of  the  instrument,  and  there  is  appar- 
ently considerable  increase  in  the  median  portion  of  the  prostate. 

Preliminary  treatment. — Urotropin,  lithia  water.  Under  this  treatment 
the  patient  improved  considerably. 

Operation,  November  12,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Extraction  of  calculi  through  the  perineum.  The  lat- 
eral lobes  were  moderately  enlarged  and  easily  enucleated.  It  was  im- 
possible to  engage  the  middle  lobe  with  the  tractor  which  was  then 
withdrawn  and  the  finger  inserted.  The  median  lobe  was  then  easily 
pushed  into  the  left  lateral  cavity  where  it  was  enucleated  and  proved 
to  be  about  2  cm.  in  diameter.     The  left  lateral  wall  of  the  urethra  was 


282  Hugh  H.  Young. 

torn,  and  the  remainder  was  divided  with  the  scissors  and  the  neck  of 
the  bladder  dilated  before  the  insertion  of  stone  forceps.  The  two  cal- 
culi were  easily  extracted,  measuring  2  x  21/0  x  3  cm.  and  1  x  2  x  2^^  cm. 
The  urethra  was  not  sutured  and  the  wound  was  closed  as  usual  with 
double  tube  drainage  for  the  bladder  and  light  gauze  packs  for  the  lat- 
eral cavities.  A  submammary  infusion  was  started  on  the  table  and  a 
continuous  irrigation  after  the  patient's  return  to  the  ward.  The  patient 
stood  the  operation  well,  his  pulse  at  the  end  being  80. 

Convalescence. — The  patient  reacted  well.  The  temperature  reached 
101.2°  on  the  second  day  and  was  practically  normal  after  the  third 
day.  The  tubes  and  gauze  were  removed  on  the  second  day,  the  irriga- 
tion having  continued  for  48  hours.  The  patient  was  walking  within 
a  week.  Urine  came  through  the  penis  on  the  seventh  day,  and  the  fis- 
tula closed  on  the  12th  day.  He  was  discharged  from  the  hospital  on 
the  18th  day. 

December  1,  i90^.— >(19th  day).  The  patient  voids  urine  at  intervals 
of  two  hours.  He  has  good  control,  but  there  is  slight  dribbling  at  the 
end  of  urination.  The  stream  is  large  and  he  suffers  no  pain.  A  cath- 
eter passes  with  ease  and  finds  10  cc.  residual  urine.  The  bladder  ca- 
pacity is  250  cc. 

February  28,  1905. — The  patient  has  gained  23  pounds  since  opera- 
tion. Retains  urine  for  five  hours  during  the  day  and  arises  twice  dur- 
ing the  night.  A  catheter  enters  with  ease  and  there  is  no  stricture 
present  and  no  residual  urine.  The  bladder  capacity  is  300  cc.  The 
cystoscope  shows  a  slightly  irregular  prostatic  margin  with  a  small  al- 
most pedunculated  redundant  fold  of  mucous  membrane  in  the  anterior 
portion  of  the  left  lateral  lobe.  With  finger  in  rectum  and  cystoscope  in 
urethra  the  median  portion  of  the  prostate  is  about  normal  in  size. 

November  30,  1905. — Letter.  I  void  urine  as  well  as  I  ever  could,  once 
during  the  night,  a  little  more  frequently  during  the  day  and  about  half 
a  pint  at  a  time.  I  suffer  no  pain,  the  wound  is  healed,  and  I  am  cured.  I 
have  had  no  erections.  In  August,  1905,  the  right  testicle  became  swol- 
len.   My  general  health  is  good  and  I  have  gained  45  pounds. 

May  8,  1906. — Letter.  I  void  urine  naturally,  once  during  the  night  and 
six  times  during  the  day,  about  half  a  pint  at  a  time.  I  suffer  no  pain. 
I  have  imperfect  erections,  but  have  not  attempted  intercourse.  My  gen- 
eral health  is  good  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  119,  consists  of  seven  lobules, 
weighing  in  all  38  gm.  The  left  lateral  lobe  is  the  larger  and  has  been 
removed  in  two  pieces.  The  median  lobe  measured  about  2.5  cm.  in  diam- 
eter. The  character  of  the  prostatic  lobes  is  about  the  same,  irregularly 
lobulated,  and  the  cut  surface  is  fairly  firm  with  two  dilated  ducts  and 
little  demarcation  into  spheroids.  Two  stones  are  also  preserved,  the 
larger  measuring  3  x  2.5  x  2  cm. 

Microscopic  examination. — ^The  hypertrophy  is  a  distinctly  glandular  one 
with  a  tendency  to  arrangement  of  the  gland  tissue  in  lobules.  The  acini 


study  of  lJf-5  Cases  of  Perineal  Prostatectomy.  283 

are  for  the  most  part  slightly  dilated,  and  are  often  closely  set  with  but 
slender  bands  of  stroma  interlacing  between  them.  Areas  are  seen  where 
there  is  marked  intraacinous  proliferation  in  the  shape  of  slender  pedicles 
of  connective  tissue,  occasionally  containing  some  few  muscle  fibers, 
lijied  by  epithelium  similar  to  the  epithelium  lining  the  acini.  The  stroma 
in  places  contains  some  young  connective  tissue  even  in  areas  where  there 
is  no  prostatitis  present.  The  stroma  altogether  contains  much  more  con- 
nective tissue  than  muscle.  Some  areas  of  chronic  prostatitis  are  present. 
The  middle  lobe  is  distinctly  more  fibrous  than  the  lateral  lobes,  and 
there  is  present  quite  a  marked  prostatitis  with  partial  atrophy  in  many 
areas  of  the  gland  tissue.    Very  few  corpora  amylacea  are  seen. 

Case  63. — Considerable  enlargement  of  median  and-  lateral  lobes.  Sev- 
eral previous  suprapubic  operations  for  calculus  and  hemorrhages.  Peri- 
neal prostatectomy.  Natural  urination  established.  Suprapubic  fistula 
failed  to  close.  Operation.  Excision  of  suprapubic  scar  tissue  and  fistula. 
Excision  of  median  portion  of  prostate.    Still  in  hospital. 

No.  1326.     C.  R.  P.,  age  75,  widowed,  admitted  October  11,  1904. 

Complaint. — Bleeding  from  the  bladder,  and  suprapubic  fistula. 

The  patient  had  gonorrhoea  in  1875  with  no  complication. 

Present  illness  began  16  years  ago  with  frequent  urination,  and  during 
the  next  two  years  he  had  frequent  attacks  of  gravel,  often  a  dozen  in 
quick  succession.  He  had  no  pain  or  hematuria  until  1891  when  he  passed 
blood  for  three  days  and  urination  was  very  frequent  and  difficult.  He 
then  catheterized  himself  and  drew  off  two  pints  of  bloody  urine.  After 
that  he  catheterized  himself  at  various  times,  sometimes  for  complete  re- 
tention of  urine,  at  others  to  relieve  a  distended  bladder.  In  August,  1897, 
he  had  considerable  hemorrhage  and  catheterization  was  difficult  on  ac- 
count of  clots.  He  then  entered  the  Johns  Hopkins  Hospital.  At  that 
time  he  was  catheterizing  himself  every  two  hours  and  was  unable  to  void 
naturally.  He  was  treated  in  the  hospital  for  five  weeks  by  catheterization 
and  vesical  irrigation.  Examination  showed  a  very  large  prostate,  and  a 
searcher  detected  calculi  in  the  bladder. 

Operation,  October  16,  1891. — Ether.  Suprapubic  cystotomy  by  Dr.  Hal- 
sted.  Two  large  stones  were  removed,  and  a  large  intravesical  and  pros- 
tatic hypertrophy  discovered.  A  hard  rubber  drainage  tube  was  sutured 
into  the  bladder. 

Convalescence. — <The  patient  remained  in  the  hospital  for  a  month.  His 
suprapubic  sinus  had  contracted  down,  and  he  was  able  to  wear  a  Blood- 
good  suprapubic  drainage  apparatus  with  comfort. 

April  21,  1899. — 'The  patient  returns,  complaining  of  leaking  around  the 
tube.  His  general  health  is  excellent  with  the  exception  of  a  chronic  bron- 
chitis. 

May  1.5,  190-'/. — ^^The  patient  returns,  complaining  of  hemorrhage  from 
the  bladder.  He  has  worn  the  Bloodgood  bag  since  1897.  During  the  last 
two  years  there  have  been  six  attacks  of  hemorrhage  from  the  bladder. 


284  Hugh  H.  Young. 

each  lasting  a  day  or  two  but  not  accompanied  by  pain.  Last  night  the 
bladder  became  distended  with  blood  and  could  not  be  emptied  either 
through  the  suprapubic  sinus  or  through  a  catheter. 

Operation,  May  17,  1904. — Ether.  Dr.  Finney.  Suprapubic  cystotomy  for 
hemorrhage  from  bladder.  The  bladder  was  exposed,  and  two  large  tortu- 
ous veins  discovered  in  the  mucous  membrane  covering  the  middle  lobe, 
from  which  there  was  considerable  oozing  of  blood.  These  points  w'ere 
seared  with  a  Paquelin  cautery  and  the  bladder  packed  with  iodoform 
gauze. 

Convalescence. — The  patient  stood  the  operation  well  and  convalesced 
nicely.  He  remained  in  the  hospital  for  28  days  and  left  in  good  condi- 
tion, wearing  a  Bloodgood  bag. 

October  11,  1904- — The  patient  returns  complaining  of  severe  hemorrhage 
from  the  bladder  which  has  been  present  for  several  days.  He  is  in  good 
condition,  his  lips  are  of  good  color,  and  his  heart  is  negative  but  for  a 
slight  systolic  murmur.  Lungs  are  clear.  There  is  a  large  suprapubic 
fistula  in  which  he  wears  a  tube  connecting  with  a  Bloodgood  bag.  The 
bladder  contains  blood  clots,  but  there  is  a  leakage  of  bloody  urine  from 
the  suprapubic  opening. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth,  elastic,  with  no 
areas  of  induration,  no  nodules. 

Preliminary  treatment. — The  bladder  was  irrigated  with  a  solution  con- 
taining adrenalin.  At  first  these  were  followed  by  considerable  hemor- 
rhage, but  after  several  days  the  hemorrhage  ceased.  The  patient  has 
worn  the  Bloodgood  tube  and  bag  for  several  years  with  comparative  com- 
fort, but  at  times  there  has  been  a  leakage  and  some  pain.  On  account  of 
the  recurrences  of  severe  hemorrhage  the  patient  was  advised  to  have  the 
prostate  removed  through  the  perineum. 

Operation,  October  20,  1904- — Young.  Ether.  Perineal  prostatectomy  by 
the  usual  technique.  The  right  lobe  was  about  7x5x4  cm.  in  size  and 
easily  enucleated.  The  left  lobe  was  somewhat  smaller.  A  median  lobe 
4  cm.  in  diameter  was  delivered  through  the  right  lateral  cavity  without 
tearing  the  urethra  or  the  bladder.  Examination  with  a  finger  in  the  su- 
prapubic wound  showed  a  small  median  bar  which  had  not  been  removed. 
It  was  not  considered  sufficiently  large  to  warrant  a  continuance  of  the  op- 
eration because  there  was  rather  more  hemorrhage  than  usual.  The  peri- 
neal wound  was  closed  with  a  catheter  and  gauze  drain,  and  another  cath- 
eter was  placed  in  the  suprapubic  wound.  Patient  stood  the  operation  well. 
Pulse  at  the  end  was  75.    Continuous  irrigation  on  return  to  the  ward. 

Convalescence. — ^The  patient  reacted  well.  The  temperature  did  not  rise 
above  100°  and  after  two  days  was  normal.  The  gauze  was  removed  on 
the  second  day  and  the  tubes  on  the  third  without  bleeding.  There  were 
considerable  nausea  and  vomiting  for  three  days,  and  the  patient  was 
given  an  infusion,  and  after  that  the  convalescence  was  uninterrupted..  The 
perineal  fistula  closed  on  the  17th  day,  and  the  suprapubic  sinus  was  then 
excised,  partially  to  hasten  its   closure.     Following  this  slight  operation 


study  of  1J/-5  Cases  of  Perineal  Frostatectomy.  285 

there  was  a  temperature  for  three  days  reaching  as  high  as  101.5°,  asso- 
ciated with  slight  nausea  and  vomiting.  No  further  rise  in  temperature. 
On  December  2,  as  the  suprapubic  sinus  still  persisted,  a  retained  catheter 
was  placed  in  the  urethra,  but  after  18  days  the  suprapubic  fistula  was 
still  patent,  and  the  catheter  was  withdrawn.  The  patient  was  discharged 
from  the  hospital  December  23,  64  days  after  the  operation.  He  was  void- 
ing urine  through  the  urethra  and  had  no  incontinence,  but  there  was 
still  a  slight  leakage  through  the  suprapubic  wound. 

May  8,  1906. — The  suprapubic  fistula  has  not  healed.  The  patient  voids 
urine  naturally  through  the  urethra,  but  if  more  than  two  hours  elapse 
urine  escapes  through  the  suprapubic  fistula.  He  catheterizes  himself- 
occasionally  and  finds  about  three  ounces  of  residual  urine.  He  has  no 
pain,  no  hematuria,  has  not  passed  a  calculus,  and  his  general  health  is 
excellent. 

Examination. — The  patient  looks  well.  There  is  a  pin-point  suprapubic 
fistula  surrounded  by  considerable  scar  tissue.  A  coude  catheter  passes 
with  ease  and  finds  about  100  cc.  residual  urine.  Bladder  capacity  is 
180  cc. 

Rectal. — In  the  median  line,  high  up,  a  globular  prostatic  enlargement 
about  2  cm.  in  diameter  is  felt.  It  is  smooth  and  soft,  and  there  is  no  in- 
duration in  the  region  of  the  vesicles.  The  cystoscope  shows  a  small 
rounded  median  lobe. 

Operation,  May  9,  1906. — Ether.  Excision  of  scar  tissue  around  the  su- 
prapubic fistula.  The  fistula  was  quite  necrotic  and  was  surrounded  by  a 
considerable  mass  of  scar  tissue.  Examination  of  the  bladder  showed  a 
transverse  septum  behind  the  ureteral  orifices  and  two  septa  running  from 
it  to  the  prostatic  orifice,  one  on  each  side.  Within  these  septa  and  be- 
hind the  prostatic  orifice  was  quite  a  deep  pouch,  apparently  about  4  cm. 
in  diameter.  There  was  a  definite  enlargement  of  the  median  lobe  in  the 
shape  of  two  small  globular  masses  with  a  sulcus  between.  These  were 
enucleated  with  the  assistance  of  a  finger  in  the  rectum  in  three  pieces 
without  removing  any  mucous  membrane.  The  prostate  orifice,  which 
was  already  enlarged,  was  considerably  enlarged  by  this  procedure.  There 
was  a  moderate  amount  of  hemorrhage  which  was  controlled  by  gauze 
packing.  The  suprapubic  wound  was  partially  closed  with  interrupted 
silver  wire.  Patient  stood  the  operation  well.  Infusion  on  the  table. 
Pulse  at  the  end  was  good. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to 
101°  on  the  second  day,  but  after  that  it  was  normal.  At  the  end  of  20 
days  the  suprapubic  fistula  showed  no  sign  of  closing,  and  a  retention 
catheter  was  placed  in  the  urethra  and  allowed  to  remain  for  a  week.  Af- 
ter its  removal  the  patient  began  to  void  at  intervals,  but  the  suprapubic 
fistula  still  leaks  slightly,  now  37  days  after  the  operation.  The  condition 
of  the  patient  is  excellent,  and  the  suprapubic  fistula  shows  every  evidence 
of  healing  soon. 

Pathological  report. — The  specimen,  G.   U.   1008,   consists  of  the  three 


286  Hugh  H.  Young. 

lobes  of  the  prostate  and  weighs  25  gm.  The  right  lobe  has  been  removed 
in  one  piece,  measures  5  x  4.5  x  3  cm.,  and  weighs  11  gm.  The  surface  is 
lobulated,  there  is  little  capsule,  and  on  section  there  is  considerable  gland 
tissue,  a  moderate  amount  of  stroma,  and  very  few  dilated  acini.  The 
left  lobe  measures  5  x  3.5  x  2  cm.,  weighs  8  gm.,  and  on  section  contains 
more  fibrous  stroma  than  the  right.  The  middle  lobe  consists  of  several 
pieces,  measuring  in  all  4  x  3.5  x  2  cm.,  and  weighing  6  gm.  The  cut  sur- 
face is  quite  smooth,  lobulation  is  not  marked,  and  condensation  at  the 
periphery  is  very  plain.  No  mucous  membrane,  no  ejaculatory  ducts,  no 
calculi. 

Microscopic  examinaMon. — The  hypertrophy  is  a  distinctly  glandular 
one.  There  is  moderate  dilatation  of  the  acini  which  are  lined  for  the 
most  part  by  two  layers  of  epithelium.  The  acini  show  the  usual  picture 
of  gland  proliferation.  The  stroma  is  comparatively  small  in  amount,  and 
it  is  mostly  composed  of  connective  tissue,  there  being  very  little  muscle 
present.  There  is  some  young  connective  tissue  in  the  stroma.  Some 
areas  of  chronic  prostatitis. 

Case  64. — Moderate  hypertrophy  of  both  lateral  lobes.  No  median  lobe. 
Catheter  life.     Cure.    Followed  IS  months. 

No.  780.    H.  W.  S.,  age  56,  widowed,  admitted  November  18,  1904. 
Complaint. — "  Enlarged  prostate — frequent  urination." 
No  history  of  gonorrhoea. 

Present  illness  began  about  five  years  ago  with  frequency  of  urination. 
This  gradually  increased  until  nine  months  ago  he  was  voiding  urine 
five  or  six  times  at  night,  felt  badly,  had  a  constant  nausea,  and  muscular 
pains  over  the  body.  In  September,  1904  (two  months  ago),  an  examina- 
tion showed  that  his  abdomen  was  distehded  and  a  catheter  withdrew  a 
quart  of  residual  urine.  Since  then  the  patient  has  been  catheterized  twice 
daily,  and  for  a  time  his  symptoms  improved.  During  the  past  two  weeks 
he  has  had  chills  and  fever,  but  has  had  no  pain.  He  has  lost  40  pounds 
in  weight  and  is  very  weak. 

8.  P. — Retention  of  urine  is  complete.  He  is  catheterized  twice  daily 
and  from  600  to  800  cc.  urine  withdrawn  each  time.  His  sexual  powers 
are  still  good. 

Examination. — The  patient  is  fairly  well  nourished,  his  lips  are  pale. 
The  chest  and  abdomen  are  negative. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  particularly 
the  left  lateral  lobe.  The  general  contour  is  rounded,  smooth  and  elas- 
tic.    The  seminal  vesicles  are  not  palpable. 

Urinalysis. — Cloudy,  sp.  gr.  1015,  reaction  acid,  no  sugar,  trace  of  albu- 
min.   Microscopically,  some  pus  cells,  no  casts. 

Preliminary  treatment. — The  patient  was  given  urotropin,  water  in 
abundance,  catheterized  at  first  twice  a  day,  from  600  to  800  residual  urine 
being  obtained,  and  later  three  times  a  day.  The  total  quantity  of  urine 
varied  from  2000  to  2700  cc.  daily.  Urea  from  8  to  16  gr.  daily.  Patient 
is  free  from  nausea  and  his  condition  seems  sufficiently  good  for  operation. 


study  of  1J/.5  Cases  of  Perineal  Prostatectomy. 


287 


Cystoscopic  examination. — The  cystoscope  shows  considerable  intravesical 
enlargement  of  both  the  lateral  lobes  with  a  cleft  between  them  in  front 
and  behind.  In  the  median  portion  of  the  prostate  is  a  transverse  fold 
of  mucous  membrane  which  is  hardly  large  enough  to  be  called  a  bar. 
The  ureters  are  easily  seen  and  appear  normal,  as  shown  in  the  accompany- 
ing chart.  Fig.  44.  In  series  D,  No.  1,  the  small  fold  behind  the  enlarged 
lateral  lobe  is  seen.  On  elevating  the  cystoscope  the  lateral  lobes  disappear 
from  view,  and  the  median  fold  is  alone  seen.  Fig.  4.  These  charts  are  in- 
teresting as  showing  how  without  taking  successive  views  it  would  be 
possible  for  the  operator  to  be  mistaken  as  to  the  size  of  the  median  fold 
which   assumes  large  proportions  when  the  handle  of  the   cystoscope   is 


Fig.  44.— Case  64. 


elevated  and  the  prism  of  the  instrument  is  in  close  contact  with  the  fold, 
thus  giving  a  greatly  magnified  view.  Figs.  X,  Y  and  Z,  however,  show 
that  the  ureters  and  interureteral  ligament  are  easily  seen. 

Operation,  November  25,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  which  were  quite  large  were  removed 
each  in  one  piece.  Examination  of  the  median  portion  of  the  prostate, 
after  enucleation  of  the  lateral  lobes,  showed  no  hypertrophied  mass,  but 
what  seemed  to  be  only  a  pronounced  vesical  sphincter.  No  definite"  median 
bar  or  lobe.  The  median  portion  was  therefore  not  removed.  The  urethra 
and  bladder  were  not  torn.  The  wound  was  closed  as  usual  with  double 
tube  drainage  for  the  bladder  and  light  packing  for  the  cavities.  There  was 
very  little  hemorrhage.  Infusion  was  given  on  the  table.  His  pulse  at 
operation  was  100°.  Continuous  intravesical  irrigation  was  instituted  on 
return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  arose  to  101° 
after  the  operation  but  was  normal  after  the  second  day.  The  irrigation 
was  continued  for  two  days  when  the  gauze  and  tubes  were  removed  and 


288  Hugh  H.  Young. 

the  patient  was  allowed  to  be  up  in  a  chair.  Urine  passed  through  the 
penis  on  the  sixth  day,  and  the  fistula  closed  on  the  10th  day.  Incontinence 
ceased  on  the  eighth  day  and  interval  urination  rapidly  increased.  The 
patient  was  discharged  on  the  16th  day  when  the  following  note  was 
made:  Urine  is  voided  in  a  large  stream  without  hesitation  about  every 
four  hours  during  the  day.  Last  night  he  did  not  urinate  from  11  p.  m. 
to  6  a.  m.  There  is  no  incontinence.  A  catheter  passes  easily,  no  ob- 
struction is  present,  and  110  cc.  urine  is  withdrawn.  The  bladder  capacity 
is  300  cc.  and  the  tonicity  good.  He  has  had  no  complications  and  no 
instrumentation  since  operation. 

'November  30,  1905. — Letter.  I  void  urine  naturally,  three  or  four  times 
during  the  day  and  twice  at  night,  in  large  amounts  as  I  drink  a  great  deal 
of  water.  I  suffer  no  pain.  The  wound  is  closed,  and  I  consider  myself 
cured.  I  have  erections  and  sexual  intercourse  is  satisfactory.  My  general 
health  is  perfect. 

May  8,  1906. — Letter.  My  condition  is  the  same  as  in  my  last  letter. 
I  void  urine  naturally,  just  as  well  as  ever.  I  have  no  pain.  Erections 
have  returned,  and  sexual  intercourse  is  somewhat  imperfect. 

Pathological  report. — The  specimen,  G.  U.  120,  consists  of  the  lateral 
lobes  of  the  prostate  each  of  which  has  been  removed  in  one  piece  and 
weighs  in  all  G-24.  The  right  lobe  weighs  G-12,  and  measures  4x3x2  cm. 
The  surface  is  smooth,  and  on  section  numerous  spheroids  with  intervening 
stroma  and  a  small  number  of  dilated  acini  are  seen.  The  left  lobe 
weighs  G-12,  and  measures  4  x  2.5  x  2.5  cm.  The  outer  surface  is  more 
lobulated.  Section  shows  numerous  large  and  small  spheroids,  consider- 
able stroma,  and  no  dilated  acini.  No  mucous  membrane  nor  ejaculatory 
ducts  have  been  removed,  no  seed  calculi. 

Microscopic  examination. — The  hypertrophy  consists  of  very  glandular 
areas  alternating  with  rather  broad  bands  of  stroma  containing  but  a  few 
acini,  most  of  which  are  small  and  flattened.  Within  the  glandular  lob 
ules  the  acini  are  rather  small,  and  the  interlacing  frame  work  is  com- 
posed of  slender  bands  containing  more  fibrous  tissue  than  muscle.  The 
stroma  in  the  extra-lobular  portions  is  rather  dense,  and  contains  slightly 
more  connective  tissue  than  muscle,  the  relative  amount  varying  in  dif- 
ferent parts.  There  are  areas  of  well  marked  interstitial  and  glandular 
prostatitis  with  numerous  leucocytes  in  the  dilated  ducts. 

Case  65. — Considerable  enlargement  of  lateral  and  median  lobes.  Pa- 
tient reacted  well,  and  progressed  well  for  three  weeks.  Death  from  pneu- 
Tnonia  2Jfth  day. 

No.  1333.    C.  B.,  age  87  years,  married,  admitted  December  3,  1904. 

Complaint. — Pain  and  difficulty  of  urination. 

Admits  having  had  gonorrhoea. 

Present  illness  began  two  years  ago  with  difficulty  in  urination.  A  little 
later  the  patient  began  to  suffer  pain  and  urination  became  very  frequent. 
For  some  time  he  has  been  using  a  catheter,  but  is  able  to  void  urine 


study  of  145  Cases  of  Perineal  Prostatectomy. 


289 


in  small  amounts.  Hematuria  has  occasionally  been  present.  He  now 
rises  10  to  12  times  at  night  to  urinate. 

Examination. — The  patient  is  poorly  nourished,  but  his  lips  are  of  good 
color.  The  radial  and  brachial  arteries  are  markedly  sclerosed.  The 
lungs  are  negative. 

Heart. — There  is  a  marked  pulsation  over  the  left  chest,  the  point  of 
maximum  impulse  being  in  the  fifth  interspace  11  cm.  from  the  median 
line.     The  heart  is  enlarged  to  the  left,  and  at  the  apex  both  sounds  are 


Fig.  45. — Large  lateral  lobes,  each  with  a  portion  of  median  lobe  at- 
tached; patient  aged  87. 


much  accentuated,  but  no  murmurs  are  heard.  Sounds  at  the  base  are 
also  clear.  The  abdomen  is  negative.  Hydrocele  is  present  on  the  right 
side.  The  penis  is  covered  with  blood  and  the  urine  which  escapes  into 
a  bottle  contains  clots  of  blood. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth  and  elastic.  Me- 
dian furrow  and  notch  not  present.  Seminal  vesicles  negative.  Urine — 
alkaline,  1011,  a  trace  of  albumin;  microscopically,  pus  cells,  granular 
casts,  and  bacteria.    Urea  G.  1.3  to  liter.     Total  amount  of  urine,  1800  cc. 

Cystoscopic. — The  patient  voided  about  50  cc.  urine.  A  small  coudg 
catheter  passes  with  ease  and  finds  only  30  cc.  residual  urine.     Bladder 


290  Hugh  H.  Young. 

capacity  is  150  cc.  and  considerable  difficulty  is  experienced  in  obtaining 
a  clear  fluid.  Hemorrhage  occurred  and  cystoscopy  is  therefore  unsatis- 
factorj\  Considerable  intravesical  prostatic  enlargement  of  the  median  and 
lateral  lobes  was  made  out,  however.  With  finger  in  rectum  and  cystoscope 
in  urethra  the  beak  could  not  be  felt  and  the  prostate  appeared  to  be  very 
large. 

Operation,  December  7,  lOOJf. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Both  lateral  lobes  were  enucleated  with  ease  and  were 
about  equal  in  size,  measuring  3x4x5  cm.  The  median  portion  of  the 
prostate  was  moderately  enlarged  and  easily  removed  through  the  lateral 
cavities.  Fig.  45.  An  anterior  intravesical  lobe  was  found  and  also  enu- 
cleated, a  tear  being  made  in  the  bladder  on  the  left  side  in  its  removal. 
The  patient  was  infused  on  the  table  and  stood  the  operation  well.  The 
wound  was  closed  as  usual  with  double  tube  drainage,  and  light  gauze 
packs  for  the  lateral  cavities. 

The  patient  stood  the  operation  well.  The  pulse  did  not  go  above  90 
and  at  the  end  was  70,  respirations  24. 

Convalescence. — The  patient  reacted  well,  the  pulse  being  80  during  the 
next  four  hours.  During  the  night  the  pulse  was  120,  and  the  patient 
complained  of  pain,  but  he  was  able  to  drink  water  in  large  amount  and 
the  next  morning  his  pulse  was  80,  and  the  temperature  normal.  For  20 
days  after  the  operation  the  temperature  was  practically  normal,  only 
once  reaching  100.6°.  His  pulse  varied  from  80  to  100.  The  tubes  were 
removed  on  the  day  after  the  operation  and  the  gauze  on  the  next  day. 
There  had  been  very  little  hemorrhage  and  the  condition  of  the  patient 
was  excellent.  After  that  the  patient  was  fairly  comfortable,  he  was  soon 
out  of  bed  and  walking  about  the  ward.  The  urine  continued  to  come 
through  the  perineum,  but  his  condition  was  greatly  improved.  On  Decem- 
ber 27,  his  pulse  was  80,  his  temperature  98°,  and  he  was  up  and  about. 
He  still  complained  of  pain  due  to  the  irritation  of  alkaline  urine  on  the 
wound,  but  his  condition  was  very  satisfactory.  On  December  28,  three 
weeks  after  the  operation  his  temperature  arose  to  100°,  on  the  next  day 
to  101°  and  on  the  next  to  102°.  Elxamination  of  the  chest  showed  a 
severe  bronchitis  associated  with  rapid  difficult  breathing  and  a  cough. 
Examination  of  the  lungs  showed  loud  moist  rales  and  loud  breath  sounds. 
After  three  days  his  condition  became  worse,  a  definite  pneumonia  was 
present,  the  temperature  rose  to  103°,  the  pulse  to  140,  and  the  patient 
died  at  4  p.  m.,  January  1,  1905.    No  autopsy  was  allowed. 

Remark. — The  patient  reacted  well  considering  his  age,  and  at  the  end 
of  the  third  week  was  walking  about,  fairly  strong  and  comfortable.  About 
this  time  there  was  a  sudden  change  in  the  weather  and  a  severe  cold 
spell  set  in.  The  patient  then  developed  pneumonia  and  died  in  five  days. 
The  operator  also  had  pneumonia  and  did  not  see  him  during  his  last 
illness. 

Pathological  report. — Specimen,  G.  U.  121,  consists  of  the  three  lobes  of 
the  prostate  removed  in  five  pieces,  and  weighs  in  all  G-101.     The  right 


study  of  llfo  Cases  of  Perineal  Prostatectomy.  291 

lobe  has  been  removed  in  two  large  pieces,  weighs  G-64,  and  measures  in 
all  7  X  5  X  3.5  cm.  The  surface  is  irregularly  lobulated  and  considerably 
torn,  and  on  section  the  tissue  is  found  to  be  composed  of  many  large 
and  small  spheroids  with  marked  cystic  dilatation  and  very  little  stroma. 
The  left  lobe  has  been  removed  in  two  pieces  and  is  similar  in  character 
to  the  right.  The  part  said  to  be  the  middle  lobe  weighs  only  G-2,  and 
measures  2  x  2  x  .8  cm.  in  size.  It  is  flat  and  on  section  shows  very  little 
glandular  tissue. 

Microscopic  examination. — The  hypertrophy  in  the  lateral  lobes  is  of  a 
distinctly  glandular  type  with  areas  of  quite  extensive  cystic  degeneration. 
The  epithelium  lining  the  acini  usually  consists  of  two  layers,  although 
here  and  there  considerable  intraacinous  proliferation  of  the  epithelium 
growing  out  into  the  lumen  in  solid  cell  masses  is  present.  The  stroma 
contains  an  unusually  large  amount  of  muscle,  but  for  the  most  part  the 
connective  tissue  element  predominates.  There  is  considerable  interstitial 
round  celled  infiltration. 

A  section  from  the  middle  lobe  shows  a  fibro-muscular  tissue  which 
contains  no  glandular  acini.  The  tissue  contains  a  large  amount  of  muscle, 
but  the  fibrous  element  probably  predominates.  There  is  present  some 
round  celled  infiltration  especially  marked  in  areas,  and  the  arteries  show 
quite  well  advanced  arteriosclerotic  changes. 

Case  66. — Moderate  enlargement  of  median  and  lateral  lohes.  Vesical 
calculus.  Two  previous  suprapubic  operations  for  calculus.  Perineal 
prostatectomy  and  lithotomy.     Cure.     Followed  two  and  one-half  years. 

S.  N.  15,927.     J.  D.,  age  54,  married,  admitted  November  30,  1904. 

Complaint. — "  Frequency  of  urination  and  pain." 

No  note  as  to  gonorrhoea. 

17  years  ago  the  patient  was  run  over  by  a  cart,  the  pelvis  and  neck  of 
the  bladder  were  ruptured,  and  extravasation  of  urine  resulted.  He  was 
laid  up  for  nine  months,  but  after  that  he  was  well  for  four  years,  when 
stricture  developed.  He  received  treatment  by  dilatations  and  was  appar- 
ently relieved.  In  1900,  the  patient  was  admitted  to  the  hospital  and 
suprapubic  cystotomy  performed  for  vesical  calculus.  He  remained  well 
for  three  years. 

About  January  1,  1904,  urination  became  difficult  and  painful  at  the 
end,  this  continued  for  three  months  when  he  entered  the  hospital  the 
second  time,  and  suprapubic  cystotomy  for  calculus  was  again  performed. 
A  calculus  about  5  cm.  in  diameter  was  removed.  The  patient  reacted  well. 
Urine  did  not  pass  through  the  urethra  until  the  31st  day,  and  the 
patient  was  discharged  on  the  48th  day. 

For  two  months  after  leaving  the  hospital  the  patient  was  very  well. 
He  then  began  to  have  frequency  of  urination,  difficulty,  and  pain  which 
has  continued  up  to  the  present  time. 

Status  prcjEsens. — Urination  difficult,  very  frequent  and  painful.  The  pain 
is  felt  at  the  neck  of  the  bladder  and  is  worse  at  the  end  of  urination, 
occasionally  slight  pain  in  the  legs.    His  general  health  is  excellent. 

Sexual  powers. — ^No  note  made. 


293  Hugh  H.  Young. 

Examination. — The  patient  is  well  nourished  with  lips  of  good  color. 
The  heart  and  lungs  are  negative  and  there  is  only  slight  arteriosclerosis. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth  and  soft.  The 
seminal  vesicles  cannot  be  reached.  On  the  left  side  the  prostate  is  ad- 
herent to  the  pelvis,  but  no  enlarged  glands  are  to  be  felt. 

Cystoscopic. — Catheter  passed  with  ease  and  found  200  cc.  residual 
urine.  The  bladder  is  contracted  and  will  not  admit  more  than  200  cc. 
of  fluid.  The  cystoscope  shows  a  large  round  stone  in  the  base  of  the 
bladder.  There  is  considerable  enlargement  of  the  lateral  lobes,  but 
owing  to  the  presence  of  stone,  the  size  of  the  middle  lobe  cannot  be 
made  out.  With  the  finger  in  rectum  and  cystoscope  in  urethra  there  is 
considerable  increase  in  the  median  portion  of  the  prostate. 

Urine. — Cloudy,  1002,  acid,  no  sugar,  no  albumin.  Microscopically,  pus 
cells  and  epithelial  cells. 

Operation,  December  10,  1904- — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Removal  of  a  large  vesical  calculus.  The  lateral  lobes 
which  were  of  considerable  size  were  very  adherent  to  the  capsule  and 
urethra,  and  were  removed  with  difficulty  in  several  pieces.  The  median 
lobe  was  only  slightly  enlarged,  but  was  removed  through  the  left  lateral 
cavity.  The  urethra  was  opened  on  the  left  lateral  wall  and  a  large  calculus 
removed  in  several  pieces.  Finger  introduced  into  the  bladder  showed 
a  small  diverticulum  about  5  cm.  in  diameter  with  its  orifice  just  behind 
the  trigone.  The  wound  was  closed  as  usual  with  double  tube  and  iodoform 
gauze  drainage.  The  patient  stood  the  operation  well,  the  pulse  at  the 
end  being  100. 

Convalescence. — The  patient  reacted  well.  His  temperature  did  not 
rise  above  101°  and  was  normal  after  the  fourth  day.  The  gauze  and 
tubes  were  removed  on  the  fourth  day,  but  urine  did  not  pass  through 
the  anterior  urethra  until  the  15th  day.  The  perineal  fistula  closed  on  the 
27th  day,  and  the  patient  was  in  excellent  condition,  but  remained  in  the 
hospital.  On  the  35th  day  there  was  a  chill  and  rise  of  temperature  to 
104°.  The  patient  had  a  slight  cough.  The  wound  was  almost  healed  and 
looked  well.  The  patient  continued  to  have  a  little  fever,  and  on  the  47th 
day  the  perineal  fistula  opened  again.  Sounds  passed  easily  into  the 
bladder  and  no  stone  was  found.  After  that  he  improved  and  was  dis- 
charged on  February  9,  1905,  the  61st  day.  The  perineal  fistula  had 
closed  finally  on  the  58th  day.  He  was  able  to  retain  urine  for  three  hours, 
was  able  to  void  urine  without  pain  or  discomfort  and  his  condition  was 
excellent. 

May  11',  1906. — Letter.  The  perineal  wound  has  remained  closed,  I  void 
urine  naturally  four  or  five  times  during  the  day  and  twice  at  night,  about 
half  a  pint  at  a  time.  I  suffer  no  pain.  Sexual  intercourse  is  satisfactory. 
I  have  had  no  complications  or  subsequent  treatment.  My  general  health 
is  better  than  ever  since  the  operation.  I  have  gained  in  weight,  and  I 
consider  myself  almost  cured. 
Pathological  report. — The  specimen,  G.  U.  123,  consists  of  three  prostatic 


study  of  lJj5  Cases  of  Perineal  Prostatectomy.  293 

lobes  (right,  left,  and  median),  and  fragments  of  a  vesical  calculus.  The 
right  lobe  weighs  G-5,  and  measures  2x2x1  cm.  in  size.  On  section 
spheroids  of  different  sizes  are  seen  with  small  cysts,  three  of  which 
contain  calculi  about  the  size  of  a  grape  seed.  In  other  places  very  small 
seed  calculi  are  seen.  The  left  lobe  weighs  G-4,  measures  2.5  x  1  x  1  cm., 
is  more  fibrous  than  the  right,  and  contains  one  grape  seed  calculus.  The 
middle  lobe  weighs  G-2,  and  measures  2  x  1  x  .6  cm.,  is  very  fibrous  and 
contains  no  calculi.  The  vesical  calculus  consists  of  a  mass  of  sand  and 
soft  stone  with  a  small  round  hard  nucleus  1.5  x  1  x  .6  cm.  in  size. 

Microscopic  examination. — The  acini  are  not  arranged  in  lobules,  but 
are  disseminated  throughout  the  stroma.  There  is  present  a  very  marked 
prostatitis  with  abundant  endoglandular  proliferation  and  degeneration 
of  epithelial  cells,  with  round  and  polynuclear  infiltration  of  the  interstitial 
tissue.  Many  of  the  arteries  show  quite  extensive  thickening.  The  middle 
lobe  is  a  moderately  glandular  one.  The  acini  are  dilated  and  show  marked 
papillomatous-like  proliferation.  The  epithelium  lining  the  acini  and  the 
papillomatous  projections  is  often  many  layers  thick,  the  lumina  some- 
times being  filled  with  epithelium  and  a  few  leucocytes.  There  is  some 
round  celled  and  polynuclear  infiltration  of  the  stroma.  The  stroma  in 
all  three  lobes  contains  considerably  more  fibrous  tissue  than  muscle. 

Case  67. — Moderate  enlargevient  of  median  and  lateral  lodes.  Chronic 
uremia,  nausea,  headache.  Chronic  nephritis.  Angina  pectoris.  Cured. 
Followed  16  months. 

No.  1053.    W.  K.,  age  70,  married,  admitted  November  23,  1904. 

Complaint. — "  Frequency  and  burning  on  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  two  years  ago  with  burning  on  urination.  Several 
months  later  he  began  to  have  considerable  frequency  of  urination  partic- 
ularly at  night,  and  was  constantly  nauseated.  During  the  last  few  months 
he  has  had  greater  difficulty  in  urination,  his  health  has  been  bad  and  he 
has  suffered  considerably  with  stomachic  disturbance  and  more  or  less 
constant  nausea.  For  several  weeks  he  has  been  under  treatment  by 
Dr.  Likes,  who  has  catheterized  him  several  times  daily.  Under  this 
treatment  he  has  improved  in  health,  but  still  feels  weak.  The  patient 
has  not  had  complete  retention.  After  voiding  a  small  amount  of  urine 
the  fiow  is  suddenly  stopped  by  a  severe  pain.  He  has  had  no  hemorrhage. 
Incontinence  is  frequently  present  at  night. 

Sexual  powers. — For  two  months  the  patient  has  had  no  sexual  desire 
or  ability  to  have  intercourse. 

Examination. — The  patient  is  well  developed,  lips  pale  and  his  skin  is 
of  poor  color.  The  chest  is  barrel  shape,  but  the  lungs  are  apparently 
negative.  The  heart  sounds  are  negative.  (The  patient,  however,  has 
had  several  attacks  of  angina  pectoris.)  The  abdomen  is  negative  with 
the  exception  of  a  distended  bladder. 

Rectal. — The  prostate  is  only  slightly  enlarged,  smooth,  firm,  no  nodules. 
The  seminal  vesicles  are  not  palpable. 


394  Hugh  H.  Young. 

Urinalysis. — Acid,  1002,  albumin  in  small  amount,  no  sugar,  microscopic- 
ally negative. 

TJrea. — G-5,  in  24  hours. 

Cysloscopic. — Catheter  passes  with  ease  and  finds  500  cc.  residual  urine. 
The  cystoscope  shows  a  small  median  lobe,  but  only  slight  enlargement  of 
the  lateral  lobes.    The  bladder  is  trabeculated,  but  only  slightly  inflamed. 

Preliminary  treatment. — The  patient  was  sent  to  the  hospital  and 
catheterized  regularly  three  times  a  day  for  a  week.  He  was  able  to  void 
from  300  to  700  cc.  daily,  but  the  catheter  removed  generally  from  500 
to  700  cc.  residual  urine  each  time.  The  total  quantity  voided  varied  from 
1200  to  1900  cc.  daily.  The  patient  was  then  discharged  and  was  treated 
at  home  by  catheterization  three  times  a  day.  Under  this  treatment  the 
patient  improved  steadily,  nausea  disappeared,  his  appetite  returned,  and 
the  sp.  gr.  of  the  urine  gradually  increased  until  it  finally  reached  1015. 
The  quantity  voided  diminished  and  the  urea  increased  from  about  5  G. 
daily  to  about  15.  After  six  weeks  his  condition  was  sufiiciently  good  to 
warrant  an  operation. 

Operation,  January  9,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  slightly  enlarged  and  were  easily 
removed.  A  small  median  lobe  was  removed  through  one  of  the  lateral 
cavities.  The  ejaculatory  ducts  were  preserved.  The  wound  was  closed 
as  usual  with  double  tube  drainage,  and  light  packs  for  the  lateral  cavities. 
The  patient  stood  the  operation  well,  pulse  at  the  end  being  100.  An 
infusion  was  given  on  the  table  and  continuous  irrigation  on  return  to 
ward. 

Convalescence. — The  patient  reacted  well.  On  the  day  after  the  operation 
the  temperature  arose  to  100°,  but  fell  to  normal  the  following  day  and  re- 
mained practically  normal  afterward.  The  gauze  and  tubes  were  removed 
on  the  third  day.  The  patient  was  up  in  a  wheel  chair  on  the  sixth  day. 
The  perineal  fistula  closed  completely  on  the  16th  day.  Epididymitis 
developed  on  the  21st  day,  and  caused  considerable  pain.  An  attack  of 
gout,  from  which  the  patient  had  long  been  a  sufferer,  showed  itself  with 
severe  pain  in  the  toe  and  knee.  Convalescence  was  therefore  delayed,  but 
the  patient  was  discharged  on  the  26th  day,  in  excellent  condition,  the 
wound  completely  closed,  voiding  urine  naturally  through  the  urethra 
without  incontinence. 

November  30,  1905. — Letter.  The  wound  has  remained  healed.  I  have 
used  no  catheter,  void  urine  naturally  about  every  two  hours  during  the 
day  and  three  or  four  times  at  night.  I  have  occasionally  sexual  desire,  but 
no  erections.  My  general  health  is  fairly  good.  At  times  I  suffer  pain 
in  the  right  testicle. 

April  21,  1906. — I  void  urine  naturally  three  or  four  times  during  the 
day  and  often  do  not  get  up  at  night.  The  stream  is  large;  I  have  no 
pain,  no  hesitation.  I  have  had  erections  and  intercourse  once  since  oper- 
ation.   My  general  health  is  excellent  and  I  consider  myself  cured. 

Urine  clear,  1014,  faint  trace  of  albumin,  no  sugar,  few  pus  cells,  few 
epithelial  cells,  no  cast  found  on  careful  search. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  295 

Pathological  report. — The  specimen,  G.  U.  125,  consists  of  the  two  lateral 
lobes  of  the  prostate  each  removed  in  two  pieces  and  weighing  in  all  0-34. 
The  right  lobe  weighs  G-13,  one  piece  measures  3.5  x  2  x  1.3  cm.  and  the 
other  2.5x2.5x1  cm.  The  surfaces  are  lobulated;  the  cut  surface  is  fairly- 
firm,  and  does  not  show  many  spheroids  or  many  dilated  acini.  The 
left  lobe  weighs  G-21,  and  the  two  pieces  measure  3.5  x  3  x  2  cm.  and  3.5  x 
2.5  X  2  cm.  Their  surfaces  are  lobulated,  encapsulated,  and  the  cut  surface 
shows  much  more  spheroid  formation  and  dilated  acini. 

Microscopic  examination. — The  hypertrophy  is  a  distinctly  glandular  one 
with  arrangement  in  lobules.  Within  the  lobules  the  acini  are  often  close- 
set,  and  small,  and  the  epithelium  usually  two  layers  in  thickness,  the 
superficial  layer  being  cylindrical  and  the  basement  cells  having  a  cuboidal 
shape.  Again  the  acini  are  dilated  and  numerous  intraacinous  projections 
are  seen.  Some  cystic  degeneration  with  fiattening  of  the  epithelium  is 
present  in  areas.  In  the  interlobular  tissue  the  stroma  is  more  abundant, 
and  the  acini  are  at  times  small  and  occasionally  much  depressed.  The 
stroma  in  the  glandular  lobules  shows  considerable  new  connective  tissue 
formation.     Some  few  areas  of  prostatitis  are  present. 

Case  68. — Moderate  enlargement  of  lateral  lobes.  Small  median  har. 
Cure. 

No.  792.    E.  L.  C,  age  71,  widowed,  admitted  December  10,  1904. 

Complaint. — "  Diflaculty  of  urination.    Catheterism  once  daily,  and  pain." 

The  patient  has  never  had  gonorrhoea. 

Present  illness  began  about  15  years  ago  with  a  slight  difiiculty  in 
urination.  10  years  ago  he  had  complete  retention  of  urine  and  required 
catheterization  once.  After  that  there  was  a  gradual  increase  in  the  diffi- 
culty and  frequency  of  urination,  and  one  year  ago  patient  was  arising 
three  times  at  night  to  urinate.  In  June,  1904,  the  second  retention  of 
urine  came  on,  a  catheter  being  passed  and  one  and  one-half  pints  of  urine 
being  removed.  Since  then  he  has  used  the  catheter  three  or  four  times 
during  the  night,  but  during  the  day  he  voids  naturally,  but  with  pain  and 
at  intervals  of  an.  hour.  The  pain  comes  on  before  and  during  urination 
and  is  referred  to  the  end  of  the  penis.  He  has  never  had  any  hematuria, 
nor  renal  colic.  He  has  had  epididymitis  once.  Erections  have  been  ab- 
sent for  five  years.  He  now  voids  every  hour  during  the  day  and  uses  the 
catheter  three  times  at  night.  He  suffers  pain  when  the  bladder  becomes 
full,  but  this  is  relieved  by  catheterization.    No  pain  in  other  locations. 

Examination. — The  patient  is  a  thin,  rather  weak-looking  man  with 
pale  mucous  membranes.  Chest  is  barrel  shaped,  expansion  poor  and  breath 
sounds  feeble.    The  heart  is  slightly  enlarged  but  otherwise  negative. 

The  prostate   is  moderately  hypertrophied,  forming  a   mass   about  the 

size  of  a  medium  sized  lemon  with  the  long  diameter  along  the  urethra, 

the  median  furrow  and   notch  being  obliterated.     The  lateral  lobes   are 

equally  enlarged,  smooth,  elastic,  and  not  tender.     The  seminal  vesicles 

Vol.  XIV.— 20. 


296  Hugh  H.  Young. 

are  not  palpable,  and  no  glands  are  to  be  felt.  The  globus  major  of  the 
right  epididymis  is  indurated  and  enlarged,  and  the  left  epididymis  is  also 
indurated,  but  not  enlarged. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  withdraws  400  cc. 
of  residual  urine.  The  bladder  capacity  is  apparently  large  and  the  ton- 
icity good.  The  cystoscope  shows  a  moderate  enlargement  of  both  lateral 
lobes  and  median  bar  confluent  with  the  right  lateral  lobe  but  separated 
from  the  left  by  a  shallow  sulcus.  The  bladder  is  markedly  trabeculated 
and  inflamed,  and  numerous  pouches  and  one  small  diverticulum  are  pres- 
ent at  the  vertex  of  the  bladder.  The  ureters  could  not  be  deflnitely  lo- 
cated. In  the  base  of  the  bladder,  just  behind  the  median  portion  of  the 
prostate,  an  irregular  dark  mass  is  seen.  It  is  partially  covered  with  mu- 
cus and  it  is  therefore  difficult  to  say  exactly  what  it  is,  though  it  is 
probably  a  blood  clot.  With  the  finger  in  the  rectum  and  cystoscope  in  the 
urethra  there  is  apparently  no  thickening  in  the  region  of  the  trigone  and 
the  median  portion  of  the  prostate  is  only  moderately  enlarged. 

Perineal  prostatectomy  was  advised  and  the  patient  returned  February  7 
for  operation,  improved  in  health. 

Second  cystoscopic  examination  showed  that  the  black  mass  had  dis- 
appeared and  there  was  nothing  to  suggest  a  neoplasm.  The  bladder  ca- 
pacity was  550  cc.  Residual  urine  250  cc.  Urine  was  cloudy  and  con- 
tained pus  and  bacilli.  Slight  cloud  of  albumin,  no  sugar.  Urea  G-10  the 
liter. 

Operation,  February  S,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  found  to  be  moderately  enlarged 
and  were  easily  enucleated,  leaving  the  urethra  and  ejaculatory  ducts 
intact.  The  median  bar  was  enucleated  through  one  of  the  lateral  cavities 
and  was  of  moderate  size.  The  wound  was  closed  as  usual  with  gauze 
for  the  lateral  cavities  and  double  tube  drainage  for  the  bladder.  Sub- 
mammary infusion  of  salt  solution  was  given  at  the  end  of  the  operation 
and  continuous  irrigation  for  the  bladder  was  started  on  the  return  to 
the  ward.  There  was  very  little  hemorrhage  and  the  patient  stood  the 
operation  well. 

Convalescence.- — The  patient  reacted  well  after  the  operation.  The 
gauze  was  removed  on  the  day  after  the  operation  and  the  tubes  on  the 
third  day,  continuous  irrigation  having  been  maintained  only  15  hours 
after  the  operation.  The  patient  was  out  of  bed  on  the  fourth  day,  but 
was  slow  in  walking.  The  urine  ceased  to  come  through  the  perineal 
fistula  on  the  28th  day.  Highest  temperature  after  the  operation  was 
100.7°,  and  temperature  was  normal  after  the  10th  day.  The  patient  was 
discharged  on  the  28th  day.  On  March  11,  the  following  note  was  made: 
The  patient  can  hold  his  urine  for  four  hours,  urination  is  free  and  the 
stream  is  large.  He  has  no  incontinence,  but  if  he  changes  his  position 
quickly  a  few  drops  may  escape.  He  is  free  from  pain  and  feels  well. 
The  wound  is  healed  with  the  exception  of  a  small  granulating  point.  The 
urine  contains  albumin  and  a  few  granular  casts. 


study  of  11)5  Cases  of  Perineal  Prostatectomy.  297 

May  12,  1905. — Tlie  patient  can  hold  his  urine  from  five  to  seven  hours. 
Goes  to  bed  at  10  o'clock  and  does  not  arise  until  five  to  urinate.  Mictur- 
ition normal. 

June  24,  190-5. — Micturition  normal,  and  at  intervals  of  from  four  to 
seven  hours.  He  has  no  incontinence,  hut  if  he  coughs  or  sneezes  some- 
times a  few  drops  escape.  A  catheter  passes  with  ease  and  finds  only  38 
cc.  residual  urine.  Bladder  capacity  about  450  cc.  The  wound  is  tightly 
healed  and  his  general  condition  is  excellent. 

The  urine  contains  only  a  slight  trace  of  albumin. 

November  30,  1905. — Letter.  The  wound  has  remained  closed.  I  void 
urine  naturally,  three  or  four  times  during  the  day  and  once  at  night. 
(After  an  interval  of  seven  hours.)  I  have  voided  as  much  as  one 
pint  at  a  time.  I  have  no  pain.  No  erections.  My  general  health  is 
good  and  I  have  gained  10  pounds. 

May  8,  1906. — Letter.  I  void  at  intervals  of  five  hours  during  the  day 
and  seven  or  eight  hours  at  night.  Urination  is  normal,  I  have  no  pain,  no 
erections.  Occasionally  I  have  a  slight  discharge  of  blood  in  the  urine, 
but  in  every  other  particular  I  am  perfectly  well  and  consider  myself 
cured. 

Pathological  report. — The  specimen  G.  U.  128,  consists  of  the  two  lateral 
lobes  of  the  prostate  each  in  one  piece  and  weighing  in  all  G-31.  The 
right  lobe  weighs  G-17,  and  measures  4.5  x  3  x  2.5  cm.  The  surface  is 
irregularly  lobulated,  and  on  section  there  are  the  usual  spheroids  and 
dilated  ducts  of  adenomatous  hypertrophy.  There  are  no  areas  of  indura- 
tion, no  calculi,  and  nothing  suggesting  malignancy.  The  left  lobe  weighs 
G-14,  and  measures  4x3x2  cm.,  and  is  similar  in  character  to  the  right. 

Microscopic  examination. — The  hypertrophy  is  a  distinctly  glandular 
one.  The  acini  are  some  small,  some  dilated,  and  in  some  areas  show 
cystic  degeneration.  At  the  periphery  of  the  glandular  lobules  the  tissue 
is  condensed,  largely  composed  of  connective  tissue,  and  the  acini  are 
flattened  and  elongated.  The  stroma  for  the  most  part  is  quite  small 
in  amount,  and  contains  a  great  deal  of  young  connective  tissue.  There 
is  present  very  little  muscle.     Some  areas  of  mild  chronic  prostatitis. 

Case  69. — Considerable  hypertrophy  of  median  and  lateral  lobes.  Renal 
infection,  fever,  suprapubic  cystotomy  previously.  Granular  casts.  Cure. 
Followed  15  months. 

No.  835.    J.  M.,  age  70,  married,  admitted  February  13,  1905. 

Complaint. — "  Prostatic  hypertrophy.     Suprapubic  fistula." 

The  patient  never  had  gonorrhoea. 

Present  illness  began  about  10  years  ago  with  frequency  of  urination. 
This  gradually  increased  until  July,  1897,  when  complete  retention  of 
urine  came  on  and  he  had  to  be  catheterized  for  several  days.  At 
periods  varying  from  a  week  to  several  months  he  would  have  attacks  of 
retention  of  urine  and  would  have  to  be  catheterized  for  a  time.  About 
five  weeks  ago  a  catheter  had  to  be  used,  and  after  being  catheterized 
three  or  four  times  a  day  for  a  period  of  two  weeks  he  became  very  ill 


298  Hugh  E.  Young. 

with  hi^h  fever  and  pain  in  the  region  of  the  left  kidney.  Diagnosis  of 
pyelitis  was  made  and  suprapubic  cystotomy  for  drainage  performed  by 
his  physician.  Since  then  urine  has  escaped  through  the  suprapubic 
wound  and  the  patient  has  improved  steadily. 

Sexual  poicers. — Erections  and  sexual  powers  normal  up  to  recent  illness. 
Examination. — The  patient  is  a  very  feeble  old  man,  his  lips  are  pale, 
and  the  lungs  are  hyperresonant  but  otherwise  normal.     The  heart  is  di- 
lated and  the  sounds  are  feeble. 

Atdomen. — There  is  no  special  tenderness,  no  enlargement  in  the  region 
of  the  kidneys.  A  small  suprapubic  sinus  is  present  in  which  a  drainage 
tube  is  fastened;  all  of  the  urine  escapes  through  the  suprapubic  tube. 
The  right  epididymis  is  indurated  and  tender  as  the  result  of  epididymitis 
three  weeks  ago. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  symmetrical, 
smooth  and  elastic.  The  urine  is  cloudy,  acid,  contains  a  large  quantity  of 
albumin,  no  sugar.  Microscopically,  pus  and  a  moderate  number  of 
granular  casts.  Urea  grams  13  to  the  liter,  total  quantity  of  urine  1.8 
liters  daily.     Sp.  gr.  1010. 

Preliminary  treatment. — The  patient  was  given  large  amounts  of  water 
to  drink  and  urotropin  for  two  days.  Cystoscopic  examination  was  not 
made  as  his  physician  reports  that  there  was  no  stone  present  and  that 
both  lateral  and  median  lobes  were  present. 

Operation,  February  15,  1905. — Perineal  prostatectomy  by  the  usual  tech- 
nique. Two  very  large  lateral  lobes  and  a  small  median  lobe  were 
enucleated.  The  lateral  lobes  were  found  to  extend  very  high  into  the 
bladder  and  crowded  in  front  of  the  urethra.  The  deeper  portion  of  the 
left  lateral  lobe  was  pedunculated,  but  was  removed  with  ease  without 
tearing  the  mucous  membrane  covering  it.  The  median  portion  of  the 
prostate  was  removed  partly  with  the  right  lateral  lobe  and  partly  with 
the  left,  leaving  an  opening  of  communication  between  the  two  lateral 
cavities  behind  the  urethra  and  in  front  of  the  ejaculatory  bridge  which 
was  not  torn.  The  wound  was  closed  as  usual  with  double  catheter 
drainage  for  the  bladder  and  light  packs  for  the  lateral  cavities.  The 
suprapubic  fistula  was  curetted  and  a  soft  rubber  catheter  fastened  in 
the  suprapubic  opening.  The  patient  was  infused  on  the  table.  His  pulse 
at  the  end  of  the  operation  was  90,  and  his  condition  excellent. 

Convalescence. — The  patient  reacted  from  the  operation  well  and  had  no 
fever.  The  gauze  was  removed  in  48  hours,  and  the  patient  sat  up  in  a 
chair.  On  the  third  day  the  tubes  were  removed.  On  the  sixth  day  there 
was  a  sudden  rise  of  temperature  to  103°  at  2  p.  m.,  and  general  malaise. 
The  physical  examination  was  negative.  The  treatment  was  active  hydro- 
therapy, hot  applications,  saline  infusion  beneath  the  breast  of  600  cc, 
salt  solution  per  rectum,  and  potassium  acetate  and  citrate.  On  the  next 
day  the  temperature  was  normal.  On  the  eighth  day  part  of  the  urine 
came  through  the  penis  and  the  patient  was  up  and  walked  about.  On  the 
16th  day  the  suprapubic  wound  closed  and  on  the  17th  the  perineal  fistula 
closed. 


study  of  140  Cases  of  Perineal  Prostatectomy.  299 

March  10,  1905. — The  patient  is  discliarged  (23(i  day).  He  lias  been 
taking  long  walks  for  several  days.  His  general  condition  is  excellent, 
botli  wounds  are  closed,  and  tie  voids  urine  naturally  at  intervals  of  four 
hours,  in  a  large  stream  without  hesitation  or  incontinence. 

November  30,  1905. — Letter.  I  void  urine  naturally,  five  times  during  the 
day  and  twice  at  night,  about  10  ounces  at  a  time  and  without  pain.  No 
instrument  has  been  passed  since  the  operation  and  I  have  had  no 
complication.     I  consider  myself  cured.     I  have  had  no  erections. 

May  8,  1906. — Letter.  I  void  urine  naturally,  about  eight  times  during 
the  day  and  three  times  at  night,  sometimes  as  much  as  nine  ounces 
at  a  time.  I  suffer  a  slight  pain  when  my  bladder  becomes  inflamed.  I 
have  not  had  erections.    My  general  health  is  good. 

Pathological  report. — The  specimen,  G.  V.  129,  consists  of  the  median 
and  the  two  lateral  lobes  of  the  prostate,  each  removed  in  one  piece  and 
weighing  in  all  G-62.  The  left  measures  5  x  3.8  x  2.5  cm.  and  weighs  G-24, 
is  in  the  form  of  a  smooth  oval  mass  and  shows  on  section  the  typical 
spheroid  with  intervening  stroma,  dilated  glands  and  peripheral  conden- 
sation. The  right  measures  4.5x3x3  cm.  and  is  similar  to  the  left. 
The  middle  measures  3x3x4  cm.  in  size,  and  weighs  G-17,  and  is  similar 
in  appearance  to  the  lateral  lobes.  No  mucous  membrane  or  ejaculatory 
ducts  have  been  removed.     The  consistence  is  everywhere  elastic. 

Microscopic  examination. — The  hypertrophy  is  of  a  lobulated  glandular 
type,  the  gland  tissue  being  much  in  excess  of  the  stroma.  The  acini  are 
some  about  normal  in  size,  others  are  dilated,  and  again  in  some,  cystic 
degeneration  is  present.  The  stroma  contains  a  fair  amount  of  muscle, 
which  is  less  in  amount  than  the  connective  tissue.  The  vessels  are  ap- 
parently normal,  a  few  corpora  amylacea  are  seen. 

Case  70. — Moderate  enlargement  of  median  and  lateral  lodes  of  prostate. 
Previous  suprapubic  cystotomy.  Perineal  prostatectomy.  Removal  of 
tv)0  vesical  calculi.  Recurrence  of  calculus.  Liiholopaxy  unsuccessful. 
Perineal  lithotomy.  Cure.    Followed  nine  months. 

No.  730.    W.  C.  v.,  age  62,  married,  admitted  September  27,  1904. 

Compaint. — "  Enlarged  prostate  and  suprapubic  fistula." 

No  history  of  gonorrhoea. 

Present  illness  began  20  years  ago  with  frequency  of  urination.  This 
gave  patient  very  little  trouble  until  four  years  ago,  since  when  he  has  had 
considerable  difiiculty  and  frequency  of  urination,  and  at  times  very  great 
pain  with  inability  to  void  urine  until  he  has  waited  half  an  hour.  Two 
years  ago  he  had  an  attack  of  suppression  of  urine,  the  catheter  finding 
no  urine  in  the  bladder.  Two  months  later  suprapubic  cystotomy  was 
done  to  relieve  pain  and  frequency  of  urination.  During  the  past  two 
years  the  patient  has  worn  a  suprapubic  drainage  tube  and  no  urine  has 
come  through  the  urethra.  During  the  past  two  months  he  has  had  sev- 
eral attacks  characterized  by  severe  pain  beneath  the  ribs  and  in  the  back 
on  both  sides.  He  has  had  gravel  in  the  urine  for  over  a  year  and  con- 
stantly a  dull  pain  in  the  region  of  the  bladder  and  occasionally  hematuria. 

Sexual  powers. — 'No  note  made. 


300  Hugh  H.  Young. 

Examination. — 'The  patient  is  a  well  nourished  man  with  lips  of  good 
color.  Chest  negative.  In  the  hypogastric  region  is  a  sinus  in  which  the 
patient  is  wearing  a  tube  which  leads  into  the  bladder. 

Rectal. — The  prostate  is  considerably  enlarged,  soft,  smooth,  and  not 
tender.  Upper  limits  difficult  to  reach.  The  bladder  capacity  is  325  cc. 
when  filled  through  the  suprapubic  wound.  The  urine  is  cloudy,  acid, 
1020,  no  sugar,  no  albumin.  Pus  cells  present,  but  no  casts.  Urea  12  gm. 
to  the  liter. 

Preliminary  treatment. — The  patient  promised  to  return  for  operation, 
and  in  the  meantime  he  was  told  to  drink  water  in  abundance  and  to  take 
urotropin.  He  returned  February  14,  1905,  when  his  condition  was  about 
the  same  with  the  exception  that  he  was  passing  considerable  gravel  and 
his  urine  was  very  irritating.  He  was  able  to  pass  small  amounts  through 
the  urethra. 

Operation,  February  IS,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Two  moderately  enlarged  lateral  lobes  were  easily  enu- 
cleated and  a  large  median  lobe  was  drawn  down  by  the  tractor  into  the 
left  lateral  cavity  and  enucleated,  a  small  area  of  vesical  mucosa  coming 
away  attached  to  it.  Examination  with  the  finger  showed  no  remaining 
enlargement  of  the  prostate.  "With  stone  forceps  two  small  irregular  soft 
calculous  incrustations  were  removed.  After  careful  search  no  other  cal- 
culi were  found.  The  bladder  is  markedly  trabeculated  and  there  are 
numerous  pouches.  Patient  stood  the  operation  well,  pulse  at  the  end  be- 
ing 105.  The  wound  was  closed  with  a  single  perineal  drainage  tube,  the 
lateral  cavities  being  packed  with  gauze. 

Convalescence. — 'The  patient  reacted  well.  The  temperature  rose  to 
100.6°  on  the  day  after  the  operation,  but  was  normal  again  in  two  days. 
The  gauze  and  tubes  were  removed  in  48  hours.  He  was  nauseated  and 
refused  nourishment  several  times  and  was  infused  in  order  to  avert 
uremia.  During  the  second  week  the  patient  began  to  complain  severely 
of  a  pain,  frequent  micturition  and  vesical  spasm.  These  symptoms  per- 
sisted and  on  March  24  cystoscopic  examination  was  performed.  A  cath- 
eter passed  with  ease,  found  40  cc.  residual  urine,  and  bladder  capacity 
of  250  cc.  The  cystoscope  showed  a  rough  white  calculus  lying  on  the 
trigone  just  back  of  the  prostatic  orifice.  The  suprapubic  wound  closed, 
the  patient  was  voiding  urine  at  intervals  of  two  hours,  but  the  perineal 
fistula  was  still  open. 

Operation  II,  March  30,  1905.— Attempt  at  litholapaxy.  The  stone  was 
felt  in  passing  into  the  bladder,  but  no  stone  could  be  caught  with  the 
forceps.  The  operation  was  therefore  given  up.  Shortly  afterward  the 
patient  had  a  chill  and  temperature  of  101.5°,  nausea  and  vomiting. 

April  9,  1905.-^I)nvmg  the  past  10  days  the  patient  has  been  in  a  weak, 
stupid  condition.  At  times  he  has  had  hiccoughs,  nausea  and  vomiting. 
His  temperature  has  been  as  high  as  103.5°,  and  there  has  been  a  daily 
rise  to  two  or  three  degrees  above  normal  every  day.  He  has  been  infused 
several  times,  but  his  condition  is  not  good. 


Study  of  lJf5  Cases  of  Perineal  Prostatectomy.  301 

April  11,  1905. — Operation  III. — Ether.  Enlargement  of  perineal  fistula. 
Extraction  of  small  rough  calculus  from  dilated  prostatic  urethra.  The 
stone  was  found  lying  just  in  front  of  the  vesical  orifice  in  a  much  dilated, 
pouch-like,  prostatic  urethra.  It  v/as  easily  extracted  and  examination  of 
the  bladder  showed  no  other  calculi.  A  drainage  tube  was  inserted.  An 
infusion  was  given  on  return  to  ward.  Pulse  during  the  operation  was 
bad,  being  135  at  the  end. 

Convalescence. — iThe  patient  reacted  well  and  began  to  improve  at  once. 
The  temperature,  after  two  days,  was  normal,  and  the  patient  was  soon 
out  of  bed.  On  the  sixth  day  after  the  operation  a  slight  phlebitis  of  the 
left  leg  began,  but  disappeared  in  a  week.  The  perineal  fistula  healed  on 
the  20th  day,  and  patient  was  discharged  from  the  hospital  on  May  1, 
1905.     His  condition  excellent. 

Novem'ber  30,  1905. — 'Letter.  The  wound  has  remained  healed.  I  void 
urine  naturally  about  every  two  hours  night  and  day,  but  I  void  almost 
a  pint  at  a  time,  sometimes.  I  have  no  pain,  but  occasionally  a  slight  un- 
easiness. I  have  erections  (slight)  and  occasionally  sexual  intercourse. 
The  erectal  powers  seem  greatly  diminished.  I  have  gained  in  weight 
and  my  general  health  is  good. 

Patliological  report. — The  specimen,  G.  U.  131,  consists  of  the  median 
and  lateral  lobes  of  the  prostate  which  have  been  removed  in  four  pieces 
and  weighs  in  all  50  gm.  The  right  lobe  weighs  11  gm.,  and  measures  4 
X  3.5  X  1.5  cm.  It  is  composed  of  one  large  and  one  small  piece,  and  pre- 
sents on  section  small  and  large  spheroids  with  some  dilated  acini.  The 
left  lobe  weighs  17  gm.,  and  measures  5.5  x  3.5  x  2  cm.  and  presents  the 
picture  similar  to  the  right.  The  middle  lobe  is  larger  than  either  of  the 
other  two,  weighs  22  gm.,  and  measures  6  x  4  x  1.5  cm.  The  ejaculatory 
ducts  and  the  urethral  and  vesical  mucosa  have  not  been  removed. 

Microscopic  examination. — In  this  tissue  there  is  present  a  mixed  type 
of  hypertrophy,  portions  being  rich  In  gland  tissue  with  arrangement  in 
lobules,  while  other  portions  contain  a  considerable  excess  of  stroma.  In 
the  glandular  areas  the  acini  show  the  usual  pictures,  some  dilatation,  oc- 
casional cystic  degeneration,  and  complexity  of  the  lumina  of  the  acini. 
One  sees  marked  intraacinous  proliferation,  and  numerous  solid  cell  cones 
projecting  into  the  lumina.  In  the  portions  rich  in  stroma  the  acini  are 
for  the  most  part  irregular  in  outline,  some  dilated  and  others  compressed 
with  here  and  there  evidence  of  glandular  proliferation.  The  stroma  is 
largely  composed  of  fibrous  tissue,  although  occasionally  one  notes  por- 
tions where  the  muscle  is  fairly  abundant. 

Case  71. — Moderate  enlargonent  of  median  and  lateral  lobes.  500  cc. 
residual  urine.  Previously  two  Bottini  operations  and  a  perineal  prosta- 
tectomy in  Germany.     Cure.    Peculiar  burning  in  posterior  urethra. 

No.  846.    D.  G.,  age  60,  single,  admitted  February  17,  1905. 

Complaint. — ■"  Cannot  empty  bladder." 

Gonorrhoea  several  times  during  his  youth. 


302  Hugh  H.  Young. 

Present  illness  began  about  five  years  ago  with  frequency  of  urination. 
One  year  later  he  consulted  a  surgeon  in  Germany  who  performed  the  Bot- 
tini  operation.  No  improvement  followed  this,  and  his  sexual  powers  were 
destroyed.  One  month  later  another  Bottini  was  performed,  also  without 
success.  After  this  his  frequency  increased,  and  he  had  poor  control,  and 
three  years  ago  the  same  surgeon  performed  perineal  prostatectomy.  Fol- 
lowing this  he  was  somewhat  improved,  voided  less  frequently  and  was 
fairly  comfortable  until  two  months  ago  by  which  time  urination  had  be- 
come quite  frequent,  often  every  half  hour  during  the  day  and  about  three 
times  at  night.  He  was  catheterized  by  Dr.  Likes  who  found  250  cc.  re- 
sidual urine,  and  since  then  he  has  been  catheterizing  himself  once  or 
twice  every  day. 

S.  P. — The  patient  uses  a  catheter  at  night  and  does  not  have  to  void 
again  until  morning  when  the  catheter  is  used  again.  During  the  after- 
noon he  voids  at  intervals  of  from  15  minutes  to  one  hour.  His  general 
health  is  good.    He  has  had  no  erections  since  the  first  Bottini  operation. 

Examination. — The  patient  is  a  sturdy-looking  man,  lips  of  good  color. 
Chest  and  abdomen  negative.  In  the  perineum  is  a  long  scar  commencing 
in  the  middle  line  just  back  of  the  scrotum,  and  thence  extending  back- 
ward to  within  2  cm.  of  the  anus,  from  which  point  it  curves  around 
the  left  side  of  the  anus  to  a  point  near  the  tip  of  the  cocyx. 

Rectal.— iTYlb  prostate  is  distinctly  palpable.  The  right  lobe  is  slightly 
larger  than  normal,  the  surface  being  rounded,  fairly  prominent  and  soft 
in  consistence.    The  left  lobe  is  smaller  than  normal  and  quite  hard. 

Cystoscopic. — Coude  catheter  passes  with  ease  and  finds  500  cc.  residual 
urine.  The  bladder  capacity  is  large,  tonicity  good.  Cystoscope  shows  a 
small  rounded  median  lobe  with  a  fairly  deep  sulcus  on  each  side.  The 
lateral  lobes  are  not  intravesically  hypertrophied.  The  bladder  is  consid- 
erably trabeculated  and  slightly  inflamed.  There  is  no  stone  present.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  median  portion  did  not  feel 
much  greater  than  normal  (cystoscope  in  one  of  the  sulci). 

Urinalysis. — ^Urine  cloudy,  acid,  1015,  slight  amount  of  albumin,  no 
sugar.    Microscopically,  pus  cells  and  bacilli. 

Operation,  February  20,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Considerable  scar  tissue  was  encountered,  rectum  was 
very  adherent  and  a  small  tear  was  made  in  separating  it  from  the  pros- 
tate. The  usual  bilateral  capsular  incisions  were  used  and  a  fairly  large 
right  lateral  lobe  was  easily  enucleated.  From  the  left  side  only  a  small 
mass  of  cicatricial  tissue  was  excised.  The  median  lobe  was  removed  in 
part  with  the  tissue  from  the  left  lateral,  and  in  part  separately  from  the 
mucous  membrane  covering  it.  A  finger  then  showed  a  considerable  tear 
in  the  left  lateral  wall  of  the  urethra,  but  no  remaining  prostatic  tissue 
at  the  neck  of  the  bladder.  The  rectum  was  then  closed  with  interrupted 
sutures  of  fine  silk,  two  layers  covered  in  by  a  layer  of  catgut  sutures. 
The  levators  were  also  drawn  together  with  catgut.  Double  catheter  drain- 
age and  light  packs  for  the  lateral  cavities  and  the  usual  closure.  The 
patient  stood  the  operation  well.  His  pulse  at  the  end  was  100.  Infusion 
and  continuous  irrigation  on  return  to  ward. 


study  of  145  Cases  of  Perineal  Prostatectomy.  303 

C07ivalescence. — The  patient  reacted  well,  but  complained  of  pain.  The 
tubes  and  gauze  were  removed  on  the  second  day.  He  was  kept  on  milk 
diet  for  a  week,  the  bowels  being  confined  by  a  lead  and  opium  pill.  At 
the  end  of  that  time  his  abdomen  was  distended  and  he  was  very  uncom- 
fortable. Evacuation  was  obtained  by  castor  oil  by  mouth,  and  oil  enema 
followed  later  by  soap-suds  enema.  After  that  he  was  put  on  light  diet 
and  his  bowels  moved  again  frequently.  The  rectal  wound  healed  per 
primam,  but  the  urine  did  not  come  through  the  anterior  urethra  until 
the  18th  day,  and  the  patient  complained  of  a  severe  burning  in  the  re- 
gion of  the  wound.  The  perineal  fistula  healed  on  the  25th  day,  and  he 
was  discharged  from  the  hospital  on  the  33d  day,  voiding  urine  at  inter- 
vals of  two  or  three  hours  and  very  comfortable. 

April  14,  1905. — The  patient  urinates  in  a  large  stream  at  intervals  of 
about  two  hours,  has  perfect  control,  and  no  dribbling  of  any  sort.  A 
catheter  passes  with  ease  and  finds  25  cc.  residual  urine.  The  bladder  ca- 
pacity is  275  cc.  on  forced  distention.  The  urine  is  acid  and  is  moderately 
purulent. 

November  11,  i9(?5.— Patient  urinates  two  or  three  times  during  the 
night. 

January  17,  1906. — ^^The  patient  voids  urine  satisfactorily,  but  complains 
of  a  burning  sensation  in  the  urethra  which  becomes  worse  when  the 
bladder  becomes  full  and  causes  him  to  urinate.  He  arises  twice  at  night 
and  voids  at  intervals  of  three  hours  during  the  day.  Kollmann  dilator  is 
passed,  shows  no  stricture  and  is  dilated  up  to  35. 

January  23,  1906. — 'The  patient  was  improved  for  a  few  days  after  dila^ 
tation,  but  the  burning  in  the  urethra  persists.  A  simple  lanolin  oint- 
ment is  deposited  in  the  urethra. 

February  10,  1906. — ^The  patient  still  complains  of  a  burning  in  the  deep 
urethra  which  is  more  or  less  constantly  present,  disappearing  for  a  while 
after  urination.  He  only  rises  twice  at  night  to  urinate,  and  in  the  day 
time  is  able  toi  retain  urine  for  three  hours,  but  towards  the  later  part  of 
the  interval  the  burning  becomes  very  uncomfortable.  Urine  is  voided  in 
a  large  free  stream  without  hesitation  or  difllculty.  A  silver  catheter 
passes  with  ease,  meets  no  obstruction  and  finds  25  cc.  residual  urine,  and 
a  bladder  capacity  of  500  cc. 

April  7,  1906. — ^Various  medicines  have  been  tried  without  affording  re- 
lief to  burning  in  the  urethra.     The  patient  is  otherwise  perfectly  cured. 

May  8,  1906. — ^The  patient  comes  for  examination.  He  says  he  voids 
urine  well  at  intervals  of  about  three  hours.  There  is  no  obstruction  to 
urination,  and  his  only  complaint  is  a  peculiar  burning  sensation  in  the 
posterior  urethra  which  increases  as  the  bladder  becomes  full  of  urine, 
rendering  urination  imperative.  He  has  no  severe  pain,  no  hemorrhage, 
and  the  wound  has  remained  closed.  A  catheter  passes  with  ease  and 
finds  15  cc.  residual  urine  and  a  bladder  capacity  of  400  cc.  Erections 
have  not  been  present  since  the  first  Bottini  operation.  The  urine  is 
very  slightly  cloudy  and  not  very  markedly  acid. 

Rectal  examination  is  negative;    no  prostatic  enlargement  present. 


304  Hugh  H.  Young. 

Pathological  report. — The  specimen,  G.  U.  133,  consists  of  four  pieces  of 
prostate  and  weighs  about  18  gm.,  forming  a  mass  which  measures  in  all 
4.5  X  4  X  2.5  cm.  The  regions  from  which  the  masses  came  have  not  been 
noted,  but  the  appearance  is  everywhere  the  same — small  spheroids  and 
little  masses  of  gland  tissue  separated  by  considerable  masses  of  stroma. 
No  mucous  membrane  has  been  removed.  The  ejaculatory  ducts  are  not 
present,  no  calculus. 

Microscopic  examination. — Microscopically  the  tissue  from  the  right  and 
left  lobes  shows  distinctly  more  stroma  than  gland  tissue.  One  occa- 
sionally sees  a  fair  number  of  acini  aggregated  and  surrounded  by  a  dense 
stroma  in  which  the  ducts  are  very  much  flattened.  One  sees  in  the  dif- 
ferent areas  the  picture  of  a  moderately  glandular  hypertrophy,  and  also 
pictures  of  the  fibro-muscular  type.  The  stroma  is  compact  and  contains 
a  large  amount  of  fibrous  tissue,  the  muscle  element  being  comparatively 
small.  In  the  middle  lobe  there  is  much  more  gland  tissue  present  than 
in  either  of  the  lateral  lobes,  but  even  here  the  stroma  predominates,  and 
it  contains  a  fair  amount  of  muscle.  There  are  quite  numerous  areas  of 
chronic  prostatitis. 

This  hypertrophy  would  seem  to  be  of  a  mixed  type,  the  fibro-muscular 
type  predominating. 

Case  72. — Very  great  Tiypertropliy  of  median  and  lateral  lobes  of  pros- 
tate.   Cure. 

No.  847.    J.  G.,  age  59,  married,  admitted  February  18,  1905. 

Complaint. — "  Prostatic  hypertrophy.     Catheterism." 

There  is  no  history  of  gonorrhoea. 

Present  illness  began  about  eight  years  ago  with  slight  difficulty  in  uri- 
nation. After  several  weeks  the  patient  had  retention  of  urine  which  re- 
quired catheterization.  During  the  next  three  years  urination  became 
gradually  more  difficult,  and  five  years  ago  second  retention  occurred,  and 
he  was  catheterized  a  second  time  before  micturition  was  again  estab- 
lished. After  that  the  patient  catheterized  himself  on  account  of  retention 
at  various  times,  but  the  catheter  was  not  used  regularly  every  day  until 
five  months  ago,  since  which  time  he  has  used  the  catheter  twice  daily. 
He  has  very  little  pain,  and  his  general  health  has  been  good.  For  the 
last  two  weeks  his  bladder  has  been  irritable  and  painful,  and  he  has  had 
a  dull  pain  beneath  the  ribs  on  the  left  side. 

8.  P. — 'He  now  uses  the  catheter  three  or  four  times  a  day  and  can  void 
only  small  amounts  of  urine.  The  catheter  passes  with  ease,  and  there  is 
no  hemorrhage,  and  no  pain  except  in  the  bladder. 

Sexual  powers. — -The  patient  has  erections,  but  has  not  attempted  inter- 
course for  eight  months. 

Examination. — 'The  patient  is  well  nourished,  with  lips  of  good  color. 
Heart,  lungs  and  abdomen  are  negative.    There  is  no  hernia  present. 

Rectal  examination. — -The  prostate  is  of  great  size,  the  transverse  diam- 
eter being  about  four  inches,  the  longitudinal  less,  but  difficult  to  estimate 
as  the  finger  cannot  pass  the  upper  end.    The  prostate  bulges  far  towards 


study  of  lJj.5  Cases  of  Perineal  ProstoAedomij.  305 

the  rectum,  it  is  elastic,  but  firmer  than  normal,  smooth,  and  there  are 
no  nodules  or  areas  of  induration  present.  No  enlarged  glands  are  felt  and 
the  prostate  is  not  tender.  An  attempt  was  made  to  catheterize  the  pa- 
tient, but  an  impassable  obstruction  was  met  11  inches  from  the  meatus. 
Hemorrhage  was  produced,  and  cystoscopic  examination  was  therefore 
not  attempted. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1020,  albumin  a  slight  trace,  sugar 
none,  urea  11  grams  to  the  liter.     Microscopically,  pus  and  bacteria. 

Freliminary  treatment.- — -The  patient  remained  in  the  hospital  10  days 
before  operation.  Owing  to  difiiculty  of  catheterization  a  retained  cath- 
eter was  employed.  On  February  22  the  patient  developed  a  marked 
pleurisy  on  the  left  side,  but  his  temperature  did  not  go  over  100°,  and 
after  a  few  days  the  pain  disappeared  and  the  chest  was  clear. 

Operation,  February  28.  190-5. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  proved  to  be  very  large  and  were 
easily  enucleated  without  tearing  the  urethra.  The  median  lobe  was  im- 
mense and  in  removing  it  through  the  right  lateral  cavity  a  tear  was  made 
in  the  urethra,  but  no  mucous  membrane  was  removed  and  the  bladder 
was  uninjured.  The  entire  tissue  removed  weighed  145  grams.  The 
wound  was  closed  as  usual  with  double  catheter  drainage  and  light  gauze 
packs  for  the  lateral  cavities.  The  patient  was  infused  on  the  table  and 
continuous  vesical  irrigation  was  provided  on  return  to  the  ward.  The 
patient  stood  the  operation  well.     His  pulse  at  the  end  was  80. 

Convalescence. — >The  highest  temperature  after  the  operation  was  on 
the  second  day,  99.8°.  All  drainage  was  removed  in  48  hours.  For  one 
week  there  was  incontinence  of  urine,  and  after  that  the  patient  was  able 
to  void  at  intervals  of  two  hours  at  first.  Urine  began  to  flow  through  the 
penis  on  the  13th  day,  and  the  perineal  fistula  closed  on  the  18th  day. 

March  23,  1905. — 'Last  night  the  patient  slept  five  hours  without  urinat- 
ing. He  voids  urine  in  a  large  stream  and  without  hesitation,  and  has  no 
incontinence,  except  that  when  the  desire  to  urinate  comes  on  a  few  drops 
may  escape  before  he  can  void.  He  suffers  very  little  pain.  A  catheter 
passes  with  ease,  and  no  residual  urine  is  present.  The  bladder  holds  320 
cc.  Urine  is  acid,  sp.  gr.  1015,  and  there  is  a  small  amount  of  albumin, 
some  pus  cells  and  bacilli. 

March  25,  1905. — -The  patient  is  discharged  to-day.  His  condition  is  ex- 
cellent. 

April  3,  1905. — .Letter.  At  times  I  can  hold  my  urine  for  four  hours, 
but  when  I  become  fatigued  I  have  diflaculty  in  retaining  it. 

'November  30,  1905. — 'Letter.  I  void  urine  naturally,  three  times  during 
the  day  and  not  at  all  during  the  night,  about  a  pint  at  a  time.  The 
wound  is  closed,  and  I  consider  myself  cured.  I  have  had  no  erections. 
My  general  health  is  excellent. 

May  9,  1906. — 'Letter.  I  void  two  or  three  times  during  the  day  and 
once  at  night,  and  nearly  a  pint  at  a  time.  I  have  erections  at  night,  but 
have  not  attempted  intercourse.  My  general  health  is  excellent.  I  have 
gained  20  pounds  in  weight  and  consider  myself  cured. 


306  Hugh  H.  Young. 

Pathological  report.— ^The  specimen,  G.  U.  135,  consists  of  prostate  re- 
moved in  seven  pieces  and  weighs  145  gm.  The  median  lobe  measures 
about  7x4x3  cm.  The  intravesical  portion  of  the  right  lateral  lobe  meas- 
ures 7x5x4  cm.  The  other  masses  are  smaller,  varying  from  3  to  5  cm. 
in  diameter.  No  mucous  membrane  has  been  removed  with  the  intravesi- 
cal portions  of  the  prostate,  but  portions  of  the  lateral  walls  of  the  ure- 
thra have  been  removed  along  with  the  lateral  lobes.  The  floor  of  the 
urethra  and  the  ejaculatory  ducts  have  not  been  removed.  The  lobes  con- 
tain numerous  spheroidal  masses  of  various  sizes  more  or  less  firmly 
bound  together  by  fibrous  stroma.  The  consistence  is  elastic.  There  are 
no  areas  of  induration  and  no  suggestion  of  malignancy. 

Microscopic  examination. — fThe  hypertrophy  is  a  moderately  glandular 
one,  there  being  present  a  considerable  amount  of  stroma.  The  acini  are 
some  small,  others  dilated,  and  some  few  show  cystic  degeneration  and 
flattening  of  the  epithelium  which  consists  for  the  most  part  of  a 
single  layer  of  cells.  One  sees  in  the  same  section  areas  rather  rich 
in  gland  tissue,  and  areas  in  which  there  is  a  marked  hyperplasia  of 
the  connective  tissue  with  only  vestiges  here  and  there  of  acini.  The 
stroma  is  rather  dense.  There  are  numerous  areas  of  chronic  prostatitis 
with  periacinous  and  interstitial  inflammatory  tissue  formation.  The 
stroma  contains  more  connective  tissue  than  muscle,  although  in  places 
muscle  fibers  are  fairly  plentiful.  The  blood  vessels  seem  practically 
normal. 

Case  73. — Considerable  right  lateral,  small  median  and  left  lateral  lodes. 
Recent  complete  retention.  Residuum  80  cc.  Cure.  Sudden  death  after 
return  home — lieart  failure. 

No.  852.    J.  L.  G.,  age  67,  married,  admitted  February  25,  1905. 

Complaint. — ■"  Difiiculty  in  urination." 

The  patient  has  never  had  gonorrhoea. 

Present  illness  began  15  years  ago  with  a  slight  difficulty  and  frequency 
of  urination.  Since  then  he  has  been  subject  to  similar  attacks  which 
have  gradually  gotten  worse.  He  suffers  slight  irritation,  but  never  any 
pain.  Three  weeks  ago  complete  retention  of  urine  came  on,  and  his  phy- 
sician produced  considerable  hemorrhage  in  attempting  to  introduce  a  soft 
rubber  catheter.  A  large  silver  prostatic  catheter  entered  with  ease  and 
withdrew  a  pint  of  urine.  He  was  catheterized  for  two  days,  but  after 
that  voided  with  little  difficulty.  At  present  he  arises  three  times  at  night 
to  void  and  has  considerable  difiiculty  in  urinating.  He  suffers  very  little, 
but  he  is  afraid  to  leave  his  physician  and  his  business  requires  that  he 
take  long  trips.  He  therefore  wishes  to  be  cured.  His  sexual  powers  have 
been  absent  for  three  years. 

Examination. — The  patient  is  a  well  nourished  man,  with  lips  of  good 
color.  Thorax:  Expansion  is  fair  and  equal.  Vocal  fremitus  present 
throughout,  lungs  are  clear  on  auscultation  and  percussion.  The  heart 
sounds  are  best  heard  9  cm.  from  the  mid-line  in  the  fifth  interspace,  and 


study  of  145  Cases  of  Perineal  Prostatectomy.  307 

are  clear.  The  heart  is  negative.  The  pulse  is  regular.  The  abdomen  is 
negative.  There  is  a  right  sided  inguinal  hernia  for  which  the  patient 
wears  a  truss. 

Rectal  examination. — -Slight  hemorrhoids  are  present.  The  prostate  is 
moderately  but  distinctly  enlarged,  particularly  in  the  right  lateral  lobe, 
which  is  more  prominent,  wider  and  longer  than  normal.  The  consistence 
is  soft,  contour  rounded,  and  there  is  no  induration.  The  left  lateral  lobe 
is  only  slightly  enlarged,  end  soft.    The  seminal  vesicles  are  not  indurated. 

Cystoscopic  eo:aniination. — A  coude  catheter  passes  after  meeting  an  ob- 
struction in  the  median  portion  of  the  prostate  and  finds  80  cc.  residual 
urine.  The  bladder  capacity  is  300  cc.  and  the  tonicity  good.  The  cysto- 
scope  shows  a  small  median  bar  and  considerable  intravesical  enlargement 
of  the  right  lateral  lobe  and  a  small  left  lateral  lobe.  The  bladder  was 
moderately  trabeculated,  but  not  inflamed.  With  the  finger  in  the  rectum 
and  cystoscope  in  the  urethra  there  was  considerable  thickness  noted  in 
the  median  portion  of  the  prostate. 

Urinalysis. — Acid,  sp.  gr.  1016,  no  albumin,  no  sugar.  Microscopically, 
a  few  leucocytes.  Urea  17  grams  to  the  liter.  The  secretion  obtained  by 
prostatic  massage  is  composed  of  spermatozoa,  a  few  hyaline  and  granular 
cells;  no  pus  cell. 

Operation,  February  28,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  left  lateral  lobe  was  small,  the  median  bar  was  only 
moderately  large  and  was  removed  through  one  of  the  lateral  cavities.  The 
right  lateral  lobe  was  considerably  enlarged  and  projected  well  into  the 
bladder.  It  was  easily  enucleated  without  tearing  the  mucous  membrane 
covering  it.  A  slight  linear  tear  was  made  in  the  urethra,  but  the  floor 
and  ejaculatory  ducts  were  preserved  intact.  The  wound  was  closed  as 
usual  with  light  gauze  packs  for  the  lateral  cavities,  but  no  tube  drainage 
was  supplied  for  the  bladder.  The  amount  of  hemorrhage  was  slight,  and 
the  patient  stood  the  operation  well.  An  infusion  was  given  before  return 
to  the  ward. 

Convalescence. — On  the  day  following  the  operation  the  temperature 
arose  to  100.6°,  but  36  hours  later  it  was  normal.  The  gauze  packs  were 
removed  on  the  morning  following  the  operation,  and  the  patient  was  out 
of  bed  the  next  day.  Forty-three  hours  after  the  operation  the  patient 
passed  nearly  all  of  his  urine  through  his  penis,  and  after  the  second  day 
very  little  urine  came  through  the  perineum,  and  on  the  sixth  day  the  fis- 
tula closed  finally.  Immediately  after  the  operation  the  patient  voided 
urine  at  intervals,  at  first  every  hour,  on  the  seventh  day  every  two  hours, 
on  the  14th  day  every  three  hours,  and  on  the  21st  day  every  five  to  six 
hours.  For  the  first  two  weeks  there  was  considerable  urgency  when  the 
desire  to  urinate  came  on,  but  never  any  incontinence. 

March  21,  190-5. — iThe  patient  is  discharged  to-day  (21st  day).  For  the 
past  week  the  patient  has  been  walking  about  the  hospital  grounds.  His 
strength  normal,  general  condition  excellent,  and  urination  about  every 
four  hours  without  pain  and  with  perfect  control.  His  urine  contains  a 
few  pus  cells,  but  no  bacteria. 


308  Hugh  E.  Young. 

March  25.  1905. — Letter.  I  feel  perfectly  well.  Void  urine  at  intervals 
of  from  five  to  six  hours  without  diflBculty  or  incontinence. 

March  29.  1905.— The  patient  died  suddenly  in  his  bed  at  6  o'clock  this 
morning.  His  physician,  Dr.  E.  K.  Root,  writes  as  follows:  After  our 
patient's  return,  he  felt  perfectly  well,  passed  urine  easily  without  pain 
or  dribbling,  rose  only  once  during  the  night  and  said  he  felt  better  than 
he  had  for  two  years.  Examination  showed  a  blood  pressure  of  180  mm., 
and  I  cautioned  him  against  doing  much  work.  On  March  26  he  com- 
plained of  pain  in  his  stomach  and  vomiting.  There  was  no  increase  in 
pulse  rate.  I  prescribed  calomel,  milk  diet  and  vichy.  On  the  evening 
of  the  28th  he  felt  so  much  better  that  he  was  up  and  about  his  room,  saw 
som'^  personal  friends  and  demanded  more  to  eat,  and  said  he  would  get 
downtown  the  next  day.  Urination  was  entirely  normal.  At  6  a.  m., 
March  29,  friends  failed  to  arouse  him,  and  sent  for  me.  He  was  pulse- 
less, gasping  for  breath,  and  only  lived  five  minutes.  As  the  heart  had 
always  been  unusually  competent,  my  opinion  was,  in  view  of  the  arterial 
tension,  that  there  was  a  sudden  cerebral  hemorrhage,  probably  basilar, 
that  killed  him. 

Pathological  report. — The  specimen,  G.  U.  134,  consists  of  the  three 
lobes  of  the  prostate,  each  removed  in  one  piece,  and  a  sub-urethral  nod- 
ule, total  weight  being  31  gm.  The  median  lobe  is  the  largest  and  meas- 
-  ures  4x3x2  cm.  The  lateral  lobes  are  about  equal  in  size  and  measure 
3x2x1.5  cm.  A  globular  sub-urethral  lobule  about  1  cm.  in  diameter  is 
present.  The  tissue  removed  is  everywhere  similar  in  character,  lobu- 
lated  and  composed  of  gland  tissue  with  a  moderate  amount  of  cystic  di- 
latation, and  fair  amount  of  stroma.  No  mucous  membrane,  no  ejacula- 
tory  ducts,  no  calculi. 

Microscopic  examination. — The  tissue  in  all  three  lobes  is  of  a  rather 
glandular  type,  distinctly  adenomatous  portions  varying  with  areas  con- 
taining considerable  stroma.  There  is  the  usual  cystic  degeneration,  and 
intraacinous  proliferation.  The  stroma  is  fairly  equally  composed  of 
muscle  and  connective  tissue.     There  is  no  prostatitis  present. 

Case  74. — Moderate  hypertrophy  of  lateral  and  median  lobes.     Cure. 

No.  881.    J.  R.  G.,  age  61,  married,  admitted  March  25,  1905. 

Complaint. — "  Prostatic  hypertrophy.     Catheterism." 

Had  gonorrhoea  several  times  involving  the  testicles. 

Present  illness  began  about  two  years  ago  with  slight  difficulty  of 
urination.  Since  then  this  difficulty  has  gradually  gotten  worse.  In  June, 
1904,  the  patient  had  a  severe  attack  of  hematuria  lasting  about  24  hours. 
For  a  month  following  he  had  a  slight  amount  of  blood  often  before  and 
often  after  urination.  The  patient  has  only  had  to  get  up  at  night  to 
urinate  for  the  past  six  months,  but  of  late  his  frequency  has  grown  much 
worse,  and  unless  he  uses  a  catheter  at  bed  time  he  has  to  arise  six  or 
seven  times  during  the  night.  On  March  16,  1905,  he  had  a  chill  followed 
by  fever  and  pain  in  the  back  and  his  physician  made  a  diagnosis  of 
pyelitis. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy. 


309 


Sexual  powers.— Khovit  two  years  ago  erections  were  weak  and  inter- 
course very  unsatisfactory,  emissions  often  occurring  before  introitus. 
This  condition  remained  for  over  a  year.  For  the  past  eight  months 
intercourse  has  been  fairly  normal. 

Examination.— TY^e  patient  is  well  nourished  with  lips  of  good  color. 
Heart,  lungs,  and  abdomen  are  negative.  There  is  no  hernia  present. 
The  right  epididymis  is  indurated. 

Rectal  examination.— Yi^terndil  hemorrhoids  are  present  in  considerable 
mass.  The  prostate  is  markedly  and  symmetrically  enlarged  being 
approximately  the  size  of  a  large  lemon.  The  median  furrow  is  shallow 
and  the  notch  absent.  It  is  smooth,  soft.  The  seminal  vesicles  are  pal- 
pable and  not  indurated  and  no  enlarged  glands  are  to  be  felt.    The  urine 


Fig.  46. — Case  74. 


is  cloudy,  acid.  Sp.  gr.  1012,  there  is  no  sugar,  but  considerable  albu- 
min (5  per  cent).  Urea  14  gr.  to  the  liter.  Microscopically,  pus  cells  and 
bacilli,  no  casts  seen. 

Cystoscopic  examination. — A  coude  catheter  passes  with  ease  and  finds 
100  cc.  residual  urine.  This  does  not  represent  his  residual  as  he  was 
catheterized  one  hour  before.  (The  true  residual  is  250  cc.)  The  bladder 
capacity  is  large  and  the  tonicity  is  good.  The  cystoscope  shows  a  fairly 
large  middle  lobe  with  a  deep  sulcus  on  each  side  of  it,  as  shown  in  the 
accompanying  chart.  Fig.  46,  R.  and  L.  In  series  U'  with  the  beak  looking 
upward  the  handle  is  carried  to  the  left  so  that  as  it  is  elevated  it  passes 
into  the  sulcus  to  the  right  of  the  middle  lobe  which  becomes  progressively 
prominent,  as  shown  in  2,  3,  and  4. 

A  corresponding  set  of  pictures  is  shown  by  carrying  the  cystoscope  into 
the  sulcus  to  the  left  of  the  lateral  lobe,  as  shown  in  series  U-2,  by  carrying 
the  handle  of  the  cystoscope  to  the  right  with  the  beak  again  looking 
upward.  The  bladder  wall  is  markedly  trabeculated  with  numerous  small 
pouches,  but  with  no  definite  diverticula  and  no  foreign  bodies. 


310  Hugh  H.  Young. 

Preliminary  treatment. — The  patient  was  treated  in  ttie  hospital  one 
week  before  the  operation,  by  hydrotherapy,  urotropin,  catheterization 
twice  daily  and  vesical  irrigation.  During  this  time  his  highest  tempera- 
ture was  99.5°.  The  urine  contained  urea  17  gr.  to  the  liter.  The  daily 
amount  voided  was  from  1000  to  1300  cc,  sp.  gr.  1012. 

Operation,  March  30,  1905. — Perineal  prostatectomy  by  the  usual  tech- 
nique. The  lateral  lobes,  which  were  moderately  enlarged,  were  easily 
enucleated,  and  with  the  right  lateral  lobe  the  middle  lobe,  about  3  cm. 
in  diameter,  was  removed  in  one  piece.  The  urethra  and  ejaculatory  ducts 
were  preserved,  only  a  small  linear  tear  being  made  in  removing  the 
median  lobe.  The  wound  was  closed  as  usual  with  double  drainage  tubes 
and  light  packing  for  the  lateral  cavities.  An  infusion  was  given  on  the 
table  and  continuous  irrigation  of  the  bladder  on  the  return  to  the  ward. 

Convalescence. — The  patient  reacted  well  from  the  operation.  Temper- 
ature on  the  day  following  was  100.8°  and  was  fairly  normal  on  the  next 
day  and  remained  so.  The  packing  was  pulled  out  on  the  day  after  the 
operation  and  the  tubes  on  the  following  day.  He  was  up  in  a  wheel- 
chair on  the  fourth  day  and  began  to  walk  on  the  10th.  The  urine 
began  to  flow  through  the  urethra  on  the  fourth  day,  and  the  fistula  finally 
closed  on  the  23d  day.  Interval  urination  was  established  as  soon  as  the 
drainage  tubes  were  removed,  and  there  was  no  period  of  incontinence. 
On  the  20th  day  the  temperature  arose  to  102.5°  and  did  not  reach  normal 
for  four  days.  There  was  nothing  found  to  explain  the  temperature,  no 
epididymitis,  and  no  pain.  The  patient  was  treated  by  active  hydro- 
therapy and  soon  regained  his  strength.  He  was  discharged  on  the  30th 
day,  able  to  retain  his  urine  three  hours,  the  wound  closed  and  no 
incontinence  present.  A  silver  catheter  passed  with  ease  meeting  no  ob- 
struction and  finding  10  cc.  residual  urine.  Urinalysis  showed  pus,  a 
small  amount  of  albumin,  and  a  few  hyaline  casts. 

May  6,  1905. — Letter.  I  void  urine  three  or  four  times  at  night,  and 
have  a  slight  leakage  when  the  desire  to  urinate  comes  on.  I  drink  water 
freely  and  take  urotropin. 

May  29,  1905. — I  have  gained  nine  pounds,  sleep  well,  get  up  only  once 
or  twice  at  night  and  can  retain  my  urine  three  and  one-half  hours  during 
the  day. 

jSJ'ovemlier  2,  1905. — Letter.  I  urinate  on  going  to  bed  and  do  not  void 
again  until  6.30  in  the  morning.  Erections  have  returned  and  I  have  had 
intercourse  several  times,  twice  fairly  successfully  with  emissions. 

Kovember  30,  1905. — Letter.  I  void  urine  naturally,  only  once  during 
the  night,  six  to  eight  ounces  at  a  time.  I  suffer  no  pain  and  consider 
myself  cured.  I  have  erections,  but  they  are  slight,  and  intercourse  is  not 
satisfactory  as  a  rule. 

May  9,  1906. — Letter.  I  void  urine  naturally,  every  three  or  four  time^ 
during  the  day,  and  am  not  disturbed  from  bed  time  until  morning.  The 
amount  voided  is  about  eight  ounces  each  time.  I  suffer  no  pain.  I  have 
erections  and  sexual  intercourse  which  is  not  entirely  satisfactory,  erec- 
tions as  yet  being  somewhat  imperfect.  My  general  health  is  fine,  I  have 
gained  25  pounds  and  consider  myself  cured. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  311 

Pathological  report. — The  specimen,  G.  U.  145,  consists  of  two  pieces. 
The  larger  measures  8x4x3  cm.  and  comprises  the  median  and  right 
lateral  lobe  which  have  been  removed  in  one  piece.  The  left  lateral  lobe 
measures  3.5  x  3  x  2  cm.  in  size.  The  surface  of  the  lobes  is  somewhat 
irregular  with  numerous  small  lobules,  and  on  section  spheroids  with 
intervening  fibrous  stroma  and  occasional  dilated  acini  are  seen.  The 
specimen  weighs  about  G-40. 

Microscopic  examination. — The  tissue  is  rather  rich  in  stroma,  moder- 
ately glandular  areas  alternating  with  areas  containing  mostly  stroma. 
The  acini  are  for  the  most  part  small,  but  occasionally  areas  where  they 
are  moderately  dilated  are  seen.  The  epithelium  lining  the  culs-de-sac 
usually  consists  of  two  layers,  the  superficial  layer  being  cylindrical,  and 
the  deep  layer  on  the  basement  membrane  cuboidal  type.  There  is 
considerable  irregularity  of  the  lumina  of  the  acini.  The  stroma  shows 
considerable  young  connective  tissue,  and  there  is  a  fair  amount  of 
muscle  present.  In  some  of  the  more  fibrous  areas  the  blood  vessels 
show  considerable  arteriosclerotic  change.  There  is  present  quite  an 
extensive  chronic  glandular  and  interstitial  prostatitis. 

Case  75. — Moderate  enlargement  of  median  and  lateral  lobes.  Small 
suburethral  lobe.  Irritable  bladder.  Cystitis.  Pyelitis.  Relief  of  obstruc- 
tion. Cystitis  persists.  Examination  IJf  months  after  operation.  Residual 
urine  20  cc.  Contracted  bladder.  Small  vesical  calculus.  Suprapubic 
lithotomy.     Cured. 

No.  860.    0.  T.  S.,  age  69,  married,  admitted  March  4,  1905. 

Complaint. — "  Prostatic  hypertrophy  and  difficulty  in  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  five  years  ago  with  slight  difficulty  of  urination 
and  an  intermittent  frequency.  After  remaining  the  same  for  about  two 
years  the  difficulty  began  to  increase,  but  it  did  not  become  severe  until 
November,  1904,  when  complete  retention  of  urine  came  on.  After  one 
catheterization  he  was  able  to  void,  but  he  has  been  so  uncomfortable  that 
he  has  used  a  catheter  three  or  four  times  a  day  since.  Residual  urine 
which  at  first  was  11  ounces  has  recently  been  only  three  or  four  ounces. 
Two  months  ago  he  began  to  have  a  dull  pain  in  the  region  of  the  right 
kidney  which  was  very  tender  on  pressure,  and  this  condition  persisted 
for  four  weeks. 

S.  P. — The  patient  is  voiding  urine  very  frequently  and  suffers  con- 
siderable pain  in  the  bladder.  He  catheterizes  himself  three  times  a  day 
and  finds  from  two  to  four  ounces  of  residual  urine.  When  the  bladder  is 
emptied  with  the  catheter  he  has  a  sharp  pain  which  is  sometimes  so 
severe  as  to  require  morphia. 

Sexual  powers. — Erections  are  still  present,  but  sexual  powers  are 
unsatisfactory  on  account  of  pain  on  ejaculation. 

Examination. — Patient  is  a  well  nourished  man  with  lips  of  good  color. 
His  lungs  are  somewhat  emphysematous,  but  the  heart  is  negative.  There 
is  no  enlargement  or  tenderness  in  the  region  of  either  kidney. 

Genitalia. — The  right  globus  major  is  somewhat  indurated. 


313 


Hugh  H.  Young. 


Rectal. — The  prostate  is  moderately  hypertrophied,  contour  is  rounded, 
smooth.  The  left  lobe  is  soft  and  the  right  slightly  indurated.  The 
median  furrow  and  notch  are  shallow.  The  prostate  is  not  adherent  to 
surrounding  structures.  The  seminal  vesicles  are  not  palpable,  no  glands 
are  to  be  felt. 

Urinalysis. — Urine  is  quite  cloudy,  acid,  1020,  there  is  a  small  amount 
of  sugar  present,  a  trace  of  albumin,  microscopically,  a  few  pus  cells 
and  bacilli. 

Preliviinary  treatment. — The  patient  was  treated  four  days  before  oper- 
ation.   Urotropin,  lithia  water  in  abundance,  diabetic  diet,  catheterization. 


Fig.  47. — Median  bar,  small  suburethral  lobe,  two  lateral  lobes,  Case  75. 


and  vesical  irrigation  twice  daily.  Sp.  gr.  of  the  urine  varied  from  1010 
to  1020,  the  sugar  was  in  very  small  amount.  Urination  was  very  frequent, 
about  every  15  minutes  night  and  day,  and  there  was  considerable  pain 
in  the  bladder. 

Cystoscopic  examination. — A  catheter  passes  with  ease  and  finds  50  cc. 
residual  urine.  Bladder  is  very  small,  holding  only  175  cc.  on  forcible 
distention.  Cystoscope  shows  a  median  bar  and  two  slightly  enlarged 
lateral  lobes  with  a  small  sulcus  in  front.  Cystoscopic  examination  was 
unsatisfactory  on  account  of  hemorrhage.  No  calculus  was  seen  and  using 
the  cystoscope  as  a  searcher  it  was  impossible  to  feel  one.    With  finger  in 


study  of  IJfO  Cases  of  Perineal  Prostatectomy.  313 

rectum  and  cystoscope  in  urethra  the  median  portion  of  the  prostate  was 
thickened  and  lengthened. 

Note. — During  the  six  days  in  the  hospital  very  little  residual  urine 
was  obtained  with  the  catheter,  the  bladder  was  very  small  and  irritable, 
and  urination  was  painful.  Prostatectomy  to  be  followed  by  vesical  dila- 
tation was  advised. 

Operation,  March  10,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  right  lateral  lobe  was  larger  than  the  left,  measuring 
6x3x3  cm.  in  size.  The  median  bar  was  removed  partly  through  each 
lateral  cavity,  Fig.  47.  Examination  then  showed  a  globular  suburethral 
mags  about  the  size  of  a  cherry,  this  was  shelled  out  with  great  ease 
without  tearing  the  mucous  membrane  covering  it.  This  seemed  to  be 
an  enlargement  of  the  prespermatic  group  of  glands  and  was  entirely 
suburethral.  The  floor  of  the  urethra  and  ejaculatory  ducts  were  not 
disturbed,  but  a  slight  tear  was  made  in  the  lateral  wall  of  the  urethra  on 
each  side.  A  finger,  inserted  after  removal  of  the  tractor,  showed  no 
remaining  enlargement.  The  bladder  was  searched  with  a  long  spoon  and 
no  calculus  found.  The  wound  was  closed  as  usual  with  double  catheter 
drainage  for  the  bladder  and  light  gauze  packs  for  the  lateral  cavities. 
Patient  stood  the  operation  well.  His  pulse  at  the  end  was  75.  Sub- 
mammary infusion  was  given  on  the  table,  and  intravesical  irrigation 
after  return  to  ward. 

Convalescence. — The  patient  reacted  well,  the  highest  temperature 
being  on  the  day  after  the  operation,  100.4°;  after  three  days  it  was  prac- 
tically normal.  The  gauze  drain  was  removed  in  18  hours  and  the  tubes  in 
24  hours.  He  was  out  of  bed  in  a  wheel  chair  on  the  second  day  and 
began  to  walk  on  the  third.  Urine  came  through  the  penis  on  the  second 
day  and  the  fistula  closed  on  the  sixth  day.  Incontinence  ceased  on  the 
fifth  day,  and  at  the  end  of  two  weeks  the  patient  was  holding  his 
urine  for  two  hours.  The  patient  was  discharged  on  the  23d  day.  At 
that  time  the  wound  was  firmly  healed,  the  urine  was  voided  at  intervals 
of  two  to  three  hours  without  hesitation  or  pain,  a  catheter  passed 
with  ease  meeting  no  obstruction  and  finding  no  residual  urine.  The 
bladder  capacity  was  250  cc.  No  stone  could  be  felt.  Urine  was  slightly 
cloudy  and  contained  pus  and  bacilli. 

November  30,  1905. — Letter.  I  have  not  used  a  catheter,  can  void  urine 
naturally,  but  micturition  is  accompanied  by  a  scalding  pain  and  occurs 
every  two  hours  night  and  day. 

The  average  amount  voided  was  two  ounces,  the  largest  amount  seven 
ounces.    I  have  had  no  erections. 

February  5,  1906. — Urination  is  still  frequent  and  accompanied  by  a 
burning  pain.  The  amount  voided  is  usually  one  and  one-half  to  two 
ounces.  A  catheter  passes  easily,  shows  no  evidence  of  obstruction  and 
finds  no  residual  urine.  The  bladder  is  very  irritable,  the  capacity  is 
small,  holding  only  150  cc.  on  forced  distention.  The  wound  is  healed, 
and  rectal  examination  shows  no  remaining  prostatic  enlargement.  No 
evidence  of  malignancy.  The  urine  is  acid  and  very  purulent.  The 
Vol.  XIV.— 21. 


314  Hugh  H.  Young. 

patient's  physician  was  advised  to  dilate  the  bladder  forcibly  by  hydraulic 
with  an  idea  of  increasing  the  capacity  and  improving  the  cystitis.  The 
frequency  of  urination  is  evidently  due  to  irritable  cystitis  and  contracture 
of  the  bladder. 

May  14,  1906. — Patient  returns  for  examination.  He  says  that  he  has 
no  difficulty  in  urination,  but  that  he  voids  very  frequently  almost  every 
hour  night  and  day.  Since  the  operation  he  has  had  several  attacks  of  pain 
in  the  region  of  the  right  kidney,  and  during  the  past  two  months  has 
passed  about  40  small  calculi.  He  has  pain  at  the  end  of  urination  and 
in  the  end  of  the  penis. 

Examination. — The  urine  is  cloudy  and  contains  pus  and  bacilli.  A 
coude  catheter  passes  with  ease  and  finds  20  cc.  residual  uriue,  bladder 
capacity  of  125  cc.  and  quite  irritable.  The  cystoscope  shows  a  small 
irregular  white  stone  lying  in  the  right  half  of  the  bladder  but  free. 
The  vesical  mucosa  was  markedly  inflamed,  trabeculated,  and  a  shallow 
diverticulum  was  found  in  the  left  half.  Study  of  the  prostatic  orifice 
shows  a  small  but  definite  rounded  median  enlargement  with  a  cleft  on 
each  side. 

Operation,  May  18,  1906. — Ether.  Suprapubic  cystotomy.  Two  small 
calculi  were  found  and  rpmoved.  Examination  showed  a  large  prostatic 
orifice  which  easily  admitted  the  index  finger.  The  lateral  lobes  were  not 
at  all  enlarged.  In  the  median  portion  there  was  a  small  transverse  fold 
of  mucous  membrane  about  8  mm.  thick  which  was  soft  and  flabby,  but 
distinctly  elevated  above  the  trigone.  Although  the  prostatic  orifice  was 
very  large,  and  the  presence  of  only  20  cc.  of  residual  urine  showed  that 
there  was  very  little  obstruction,  it  was  thought  best  to  excise  this  median 
fold.  It  was  accordingly  caught  between  clamps  and  excised  and  a 
piece  of  tissue  about  2  cm.  wide  and  1  cm.  deep  excised  with  the  scissors 
coming  away  in  two  pieces.  Examination  showed  mucous  membrane  and 
fibrous  tissue,  no  evidence  of  prostatic  glands.  There  was  only  a 
moderate  amount  of  bleeding  and  the  bladder  was  closed  completely  with 
interrupted  catgut  sutures.  The  recti  muscles  and  skin  were  drawn 
together  with  interrupted  sutures  of  silver  wire,  with  a  small  gauze  drain- 
age at  the  lower  angle. 

Convalescence. — Immediately  after  the  operation  there  was  considerable 
intravesical  hemorrhage  with  complete  retention  of  urine.  It  was  neces- 
sary to  pass  catheters  several  times  to  evacuate  clots  of  blood.  The  patient 
suffered  a  great  deal  of  pain  and  became  quite  weak.  It  was  evident  that 
the  bladder  should  not  have  been  completely  closed  as  it  broke  down  the 
following  day.  For  a  week  the  patient  was  very  exhausted  and  his  condi- 
tion was  serious,  but  during  the  second  week  he  rallied.  On  the  14th 
day  a  catheter  was  fastened  in  the  urethra  to  hasten  closure  of  the  supra- 
pubic fistula.  It  was  removed  at  the  end  of  nine  days,  but  the  fistula 
did  not  heal  until  four  days  later,  26  days  after  the  operation. 

June  15,  1906. — The  patient  is  in  good  condition,  the  fistula  has  been 
closed  for  three  days,  he  voids  urine  without  pain,  has  no  incontinence 
and  can  retain  it  for  three  hours. 


study  of  14-5  Cases  of  Perineal  Prostatectomy.  315 

PatJiological  report. — Tte  specimen,  G.  U.  139.  The  prostate  has  been 
removed  in  four  pieces  and  weighs  3  G.  The  right  lateral  lobe  is  the 
larger,  and  measures  5x3x2  cm.,  the  left  lateral  measures  3x2x2  cm. 
The  median  bar  is  an  irregular  mass  3.5  x  2  x  1.5  cm.  in  size.  A  sub- 
urethral lobule  measures  2  xl.5  x  1.5  cm.  is  smooth  and  has  a  smooth 
capsule.  The  relative  arrangement  of  these  lobes  is  shown  in  the  accom- 
panying photograph.  The  lateral  lobes  are  composed  of  irregular  spher- 
oids, and  the  median  bar  is  of  similar  structure.  The  sub-urethral  lobule 
is  much  firmer,  and  almost  homogeneous. 

Microscopic  examination. — In  the  right  lobe  the  hypertrophy  is  a  rather 
lobulated  glandular  one  with  dilatation  and  cystic  degeneration  of  the 
acini.  The  stroma  is  largely  composed  of  fibrous  tissue,  and  there  has 
been  a  great  deal  of  new  inflammatory  tissue  formation.  In  areas  the 
new  formed  fibrous  tissue  is  leading  to  compression  of  the  acini.  The 
suburethral  lobe  is  almost  entirely  fibrous,  only  occasionally  does  one 
encounter  the  vestige  of  an  acinous.  There  is  present  very  marked  round 
cell  and  polynuclear  infiltration  with  formation  of  new  inflammatory 
tissue.  The  arteries  are  markedly  sclerosed.  In  the  right  lobe  the  arteries 
show  practically  no  thickening. 

Case  76. — Moderate  enlargement  of  median  and  lateral  lobes.  Cathet- 
erism  twice  daily.    Cure.    Folloived  14  months. 

No.  853.    F.  H.  W.,  age  63,  married,  admitted  March  7,  1905. 

Complaint. — "  Prostatic  enlargement.     Frequency  of  urination." 

Had  chronic  gonorrhcea  for  years  in  his  youth.. 

Present  illness  began  about  15  years  ago  with  slight  difficulty  of  urination, 
and  dribbling  at  the  end.  Had  very  little  trouble  until  five  years  ago  after 
which  there  was  a  considerable  increase  in  his  urinary  difficulty  and! 
frequency.  Has  never  had  complete  retention  of  urine,  but  three  months 
ago  on  the  advice  of  a  physician  he  began  the  use  of  a  catheter  at  bed 
time.  Has  had  only  slight  amount  of  pain  and  entirely  confined  to  the 
bladder.    No  hematuria. 

S.  P. — The  patient  catheterizes  himself  at  bed  time  and  after  that  he 
does  not  void  until  morning,  but  then  voids  every  hour  until  catheterized 
again.  He  has  slight  dribbling  at  the  end  of  urination,  but  suffers  no 
pain. 

Sexual  powers. — Good. 

Examination. — The  patient  is  a  sturdy  looking  man  with  lips  of  good 
color.     The  chest  and  abdomen  are  negative. 

Rectal. — The  prostate  is  moderately  enlarged,  smooth,  firm,  but  not 
markedly  indurated.    The  seminal  vesicles  are  negative. 

Urinalysis. — Cloudy,  alkaline,  sp.  gr.  1016,  no  albumin,  no  sugar,  urea 
G-12  to  liter.    Microscopically,  pus  cells  and  bacilli. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  200  cc.  residual 
urine.  The  bladder  capacity  is  about  250  cc.  The  cystoscope  shows  very 
slightly  hypertrophied  lateral  lobes  with  a  shallow  sulcus  between  them  in 
front.     There  is  a  small  but  definite  median  bar  with  no  sulci  on  either 


316  Hugh  H.  Young. 

side  behind  which  the  ureters  and  most  of  the  trigone  can  be  easily  seen. 
With  finger  in  rectum  and  cystoscope  in  urethra  the  median  portion  of  the 
prostate  is  found  to  be  only  moderately  thicker  than  normal. 

Operation,  March  11,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  left  lateral  lobe  was  smaller  than  the  right,  but  this  was 
only  moderately  enlarged,  both  were  easily  enucleated.  The  median  bar 
was  removed  in  one  piece  with  the  right  lateral  lobe  and  left  a  cavity 
beneath  the  urethra  which  formed  a  communication  between  the  two 
lateral  cavities.  The  urethra  above  it  and  the  ejaculatory  ducts  behind 
it  were  not  injured.  After  removal  of  the  tractor  a  finger  in  the  bladder 
showed  no  remaining  enlargement.  The  wound  was  closed  as  usual  with 
double  drainage  tubes  and  light  packs  for  the  lateral  cavities. 

The  patient  stood  the  operation  well,  pulse  at  the  end  72.  Continuous 
irrigation  and  infusion  on  return  to  ward. 

Convalescence. — On  the  second  day  after  the  operation  the  temperature 
arose  to  103°,  but  fell  to  normal  the  next  day,  and  afterwards  did  not  rise 
above  100°.  The  irrigation  was  discontinued  after  10  hours,  the  tubes 
removed  in  18  hours  and  the  gauze  packing  in  24  hours.  The  patient  was 
out  of  bed  on  the  fourth  day,  was  walking  on  the  sixth,  began  to  pass 
urine  through  the  anterior  urethra  on  the  fifth  day,  and  the  fistula  closed 
on  the  17th  day.  He  had  an  erection  five  days  after  the  operation.  He 
was  discharged  from  the  hospital  on  the  20th  day.  At  that  time  he  retained 
his  urine  for  four  hours,  had  no  incontinence,  except  a  slight  leakage  when 
his  bladder  became  very  full.  The  wound  was  healed.  A  catheter  passed 
with  ease  and  found  no  residual  urine  and  the  bladder  capacity  225  cc. 

May  19,  1905. — The  wound  opened  slightly  and  a  fistula  formed  after 
returning  home.     I  can  retain  urine  for  six  hours  and  am  perfectly  well. 
July  20,  1905. — Letter.     The  fistula  healed  after  several  curettements. 
His  cystitis  troubles  him  somewhat. 

November  30,  1905. — Letter.  I  void  urine  naturally,  and  often  do  not  get 
up  at  night  to  urinate  at  all.  The  amount  voided  is  about  four  ounces  and 
I  suffer  no  pain,  the  wound  is  healed  and  I  consider  myself  cured.  I  have 
erections  but  seldom,  and  intercourse  is  not  entirely  satisfactory.  My 
general  health  is  excellent. 

May  8,  1906. — Letter.  I  void  urine  as  well  as  I  ever  could,  at  intervals 
of  four  hours  during  the  day  and  only  occasionally  rise  at  night.  My 
general  health  is  excellent,  I  have  gained  16  pounds  and  am  completely 
cured. 

Pathological  report. — The  specimen,  G.  U.  142,  consists  of  the  three  lobes 
of  the  prostate  each  removed  in  one  piece,  and  weighs  about  G-21.  The 
median  lobe  is  the  largest  and  measures  2.5  cm.  in  diameter.  The  lateral 
lobes  measure  2.5  x  2.5  x  2  cm.  in  size.  The  appearance  of  the  three  lobes 
is  about  the  same,  the  external  surface  being  irregular,  and  the  cut 
surface  showing  considerable  stroma.  Very  few  dilated  acini.  No  ejac- 
ulatory ducts. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one,  the  usual  characteristic  appearance  alternating  with  broad  bands  of 


study  of  lJi-5  Cases  of  Perineal  Prostatectomy.  317 

stroma  in  which  the  acini  are  small  and  rather  compressed.  The  inter- 
stitial bands  interlacing  in  the  lobules  are  unusually  broad,  while  in  the 
areas  outside,  the  stroma  is,  as  a  rule,  in  excess  of  the  gland  tissue. 
Fairly  numerous  areas  of  interstitial  and  glandular  prostatitis  are  pres- 
ent.    The  stroma  distinctly  contains  more  muscle  than  connective  tissue. 

Case  77. — Small  sclerotic  prostate.  Vesiculitis.  Residual  urine  500  cc. 
Cured. 

No.  871.     T.  J.  E.,  age  67,  married,  admitted  March  14,  1905. 

Complaint. — "  Frequency  of  urination  and  incontinence." 

Gonorrhoea  25  years  ago,  slight  attack. 

Present  illness  began  three  years  ago  with  frequency  of  urination. 
About  the  same  time  began  to  have  slight  incontinence.  The  trouble 
increased  rapidly,  and  it  soon  became  necessary  to  defecate  in  order  to 
urinate.  At  present  he  urinates  about  every  two  hours,  and  has  great 
difficulty  in  starting  the  flow  of  urine  unless  his  bowels  move  at  the  same 
time  so  that  he  has  practiced  the  habit  of  defecating  at  each  urination. 
Urine  escapes  involuntarily  in  varying  amounts  both  night  and  day  so 
that  it  is  necessary  for  him  to  wear  a  rubber  receptacle.  Pain  has  not 
been  a  prominent  symptom  and  he  has  not  lost  weight.  He  has  never  had 
complete  retention  of  urine,  and  no  hematuria. 

Sexual  powers.— Occasionally  he  has  partial  erections,  but  he  has  been 
unable  to  have  intercourse  for  two  years. 

Examination. — The  patient  is  a  large  healthy  looking  man,  his  lips  are 
of  good  color.  The  lungs  are  clear.  There  is  a  slight  systolic  murmur 
at  the  apex,  but  the  pulse  is  good.  Abdomen  is  negative.  There  is  a 
right  inguinal  hernia  present  which  is  easily  reduced. 

Rectal. — The  prostate  is  not  much  larger  than  normal  and  does  not  bulge 
towards  the  rectum,  but  the  outlines  are  difficult  to  make  out,  the  surface 
being  irregular,  hard  in  places  and  soft  in  others,  but  there  is  no  stony 
induration,  and  no  periprostatic  induration  or  glands.  The  seminal  vesicles 
are  both  indurated  and  irregular.  Above  the  prostate  and  running  from 
one  seminal  vesicle  to  the  other  is  an  indurated  band. 

Urinalysis. — Clear,  amber.  First  glass  contains  a  few  shreds  composed 
of  epithelium.  Second  and  third  glasses  are  clear  and  contain  no  shreds. 
The  urine  is  acid.  1012,  no  albumin,  no  sugar.  Urea  G-12.5  per  liter. 
Microscopically  negative  for  bacteria  and  pus  cells. 

Cystoscopic. — A  catheter  passes  with  ease  and  finds  500  cc.  residual 
urine.  The  cystoscope  shows  very  little  enlargement  of  the  lateral  lobes, 
and  only  a  slightly  enlarged  median  bar  behind  which  the  ureters  and 
most  of  the  trigone  can  be  seen. 

Preliminary  treatment. — The  patient  was  catheterized  twice  daily  and 
took  urotropin  20  grains  a  day.  Examination  of  reflexes  showed  no  evi- 
dence of  spinal  cord  disease,  and  although  the  prostate  was  very  little 
enlarged,  the  amount  of  residual  urine  was  considerable  and  perineal  pros- 
tatectomy seemed  advisable. 


318  Hugh  H.  Young. 

Operation,  March  18,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  very  little  enlarged,  hard  and  very 
adherent.  The  median  bar  of  the  prostate  was  removed  partly  with  each 
lateral  lobe.  It  was  found  to  be  continuous  with  structures  beneath  the 
trigone  and  scissors  were  used  to  remove  it.  Examination  with  the 
finger  in  the  urethra  showed  that  the  median  bar  had  been  completely 
removed,  but  the  vesical  orifice  was  still  quite  constricted,  but  dilated  easily 
with  the  finger.  Examination  of  the  specimen  showed  that  both  ejaculatory 
ducts  had  been  removed  along  with  the  median  bar  to  which  they  were 
closely  attached  by  firm  fibrous  adhesions.  This  was  a  second  instance 
in  which  they  were  unintentionally  removed  and  in  no  other  specimens 
have  the  ducts  been  found.  The  wound  was  closed  as  usual,  but  the  hem- 
orrhage was  so  slight  that  no  drainage  tube  was  inserted,  the  lateral  cavi- 
ties being  lightly  packed  with  gauze.  Infusion  on  return  to  ward.  The 
patient  stood  the  operation  well,  the  pulse  at  the  end  being  96. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to  101° 
on  the  day  after  the  operation,  but  on  the  next  day  it  was  normal.  The 
gauze  packing  was  removed  within  24  hours  and  the  patient  was  up  in  a 
wheel  chair  on  the  second  day,  his  condition  being  excellent.  On  the 
eighth  day  slight  epididymitis  appeared  on  the  right  side,  but  under 
treatment  with  ice  it  rapidly  disappeared,  and  in  five  days  his  condition 
was  excellent.  The  urine  did  not  come  through  the  anterior  urethra 
until  the  19th  day,  and  the  perineal  fistula  did  not  close  finally  until 
the  44th  day.  From  April  6th  to  the  21st,  there  was  an  evening  rise  of 
temperature,  at  times  as  high  as  102°  and  during  this  time  the  patient  was 
drowsy,  hard  to  get  out  of  bed  and  had  very  little  appetite.  After  that 
he  was  free  from  temperature  and  improved  rapidly  in  strength.  He  left 
the  hospital  on  the  51st  day  in  good  condition,  able  to  retain  his  urine  four 
hours  at  night  and  three  hours  during  the  day,  no  dribbling,  stream 
satisfactory.  His  bowels  moved  only  once  or  twice  during  the  day  and 
he  had  good  control  of  his  rectal  sphincter  (which  he  had  not  had  for 
five  years). 

Examination. — Urine  is  voided  in  a  good  stream,  but  it  is  cloudy  and 
contains  bacilli  in  large  number.  The  perineal  wound  is  healed.  Rectal 
examination  shows  the  usual  amount  of  scar  tissue.  The  seminal  vesicles 
are  indurated,  but  there  is  nothing  to  suggest  malignancy. 

May  25,  1905. — I  can  retain  urine  three  or  four  hours  and  have  perfect 
control.    I  do  not  have  to  evacuate  my  bowels  during  urination. 

Septemter  21,  1905. — I  have  not  felt  better  for  30  years.  I  sleep  well. 
Usually  awake  at  2  a.  m.  to  urinate. 

Decemler  1,  1905. — I  have  gained  12  pounds  in  weight.  I  often  sleep 
until  4  o'clock  in  the  morning  before  urinating.  I  can  void  one  pint 
at  a  time,  have  only  a  slight  irritation  in  the  morning,  the  wound  is  closed 
and  I  consider  myself  cured. 

February  I4,  1906. — Letter.  My  frequency  of  urination  depends  upon  my 
nervousness.  If  I  know  a  urinal  is  not  convenient  I  get  nervous  and 
the  desire  to  urinate  comes  on  much  sooner  than  when  I  am  at  home  where 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  319 

I  am  able  to  retain  urine  for  two  hours.  At  times  the  stream  is  almost 
perfect,  at  others  spiral  and  forked..  I  generally  void  urine  at  two  and  at 
five  during  the  night.  Sometimes  I  pass  as  much  as  eight  ounces  at  a 
time.  There  is  a  sympathy  between  the  bladder  and  rectum,  and  if  I 
retain  the  urine  beyond  a  certain  point  I  must  empty  the  rectum  with  the 
bladder.  I  suffer  irritation  but  cannot  call  it  pain,  and  it  seems  to 
depend  upon  my  nervous  condition.  When  quiet  I  have  no  irritation  for 
hours.  My  general  health  is  better,  notwithstanding  that  I  have  been 
operated  upon  for  cataract. 

May  Ji,  1906. — The  wound  has  remained  healed,  I  void  urine  naturally, 
about  three-quarters  of  a  pint  at  a  time.  I  do  not  use  a  catheter  and 
have  only  a  slight  pain  when  the  bladder  becomes  full.  My  general  health 
is  good  and  I  consider  myself  very  much  improved. 

Pathological  report. — The  specimen,  G.  U.  141,  consists  of  the  lateral 
lobes  of  the  prostate  each  in  one  piece.  The  right  lobe  measures  3x2.5x2 
cm.  in  size.  The  surface  is  irregular,  and  at  its  upper  end  is  a  mass  of 
tissue  about  1  cm.  in  diameter  containing  the  ejaculatory  duet,  which  is 
very  easily  seen,  being  about  3  mm.  in  diameter  and  with  a  thick  white 
wall.  The  left  lobe  measures  3x3x2  cm.  in  size  and  has  a  similar  mass 
attached  to  its  upper  end  which  contains  the  ejaculatory  duct.  Section 
of  the  prostatic  lobe  shows  spheroids,  but  more  fibrous  stroma  than  usual. 
The  prostate  weighs  about  20  grams. 

Microscopic  examination. — The  hypertrophy  is  distinctly  of  the  fibro- 
muscular  type  there  being  comparatively  no  gland  acini  present.  In 
considerable  areas  almost  pure  bundles  of  muscle  fibers  are  present  while 
in  other  areas  the  fibrous  tissue  predominates.  The  few  acini  which 
are  present  are  dilated,  and  lined  by  two  layers  of  rather  flat  epithelium. 
Everywhere  is  present  much  embryonic  connective  tissue.  As  a  whole 
the  muscle  element  is  considerably  in  excess  of  the  connective  tissue,  al- 
though here  and  there  one  sees  a  rather  fibrous  nodule  with  some  round 
cell  infiltration,  but  even  here  distinct  muscle  fibers  are  present.  The 
arteries  show  a  moderate  degree  of  arteriosclerosis,  and  at  times,  especially 
in  the  larger  vessels,  the  thickening  is  marked.  There  is  present  every- 
where a  well  marked  prostatitis. 

Case  78. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Complete 
retention  of  urine.    Catheter  life.    Cured.    Followed  14  months. 

No.  877.    E.  H.  S.,  age  65,  married,  admitted  March  24,  1905. 

Complaint. — "  Enlarged  prostate.    Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  five  years  ago  with  frequency  and  precipitancy  of 
urination.  Trouble  gradually  increased,  and  four  months  ago  the  patient 
found  that  his  lower  abdomen  was  enlarged.  He  was  catheterized  and  a 
large  amount  of  residual  urine  withdrawn.  Since  then  the  patient  has  been 
unable  to  void  urine  and  has  catheterized  himself  three  times  a  day.  Has 
never  had  pain  nor  hematuria. 


320  Eugh  H.  Young. 

Sexual  powers. — Erections  are  imperfect  and  as  a  rule  not  sufficient  for 
entrance.    Sexual  intercourse  very  unsatisfactory. 

Examination. — Tlie  patient  is  a  healthy  looking  man.  Chest,  lungs,  and 
abdomen  negative. 

Rectal  examination. — The  prostate  is  only  moderately  enlarged,  soft  and 
does  not  suggest  malignancy. 

Urinalysis. — Cloudy,  acid,  sp.  gr.  1023,  albumin  in  slight  amount,  no 
sugar,  urea  24  gr.  to  the  liter.    Microscopically,  pus  cells,  bacilli,  and  cocci. 

Cystoscopic  examination. — A  catheter  passes  with  ease,  the  bladder  is 
large,  tonicity  good,  retention  of  urine  complete.  The  cystoscope  shows 
a  moderately  large  median  lobe  and  moderate  intravesical  hypertrophy 
of  the  lateral  lobes.  The  bladder  is  trabeculated  and  there  is  a  moderate 
cystitis.    No  stone  present. 

Operation,  March  27,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  were  moderately  enlarged  were  re- 
moved each  in  one  piece.  The  median  bar  and  a  pedunculated  lobe,  which 
was  attached  to  it,  were  removed  in  one  piece  through  the  right  lateral 
cavity.  A  small  tear  was  made  in  the  urethra  but  no  mucous  membrane 
was  removed  and  the  ejaculatory  ducts  were  preserved.  The  finger  was 
inserted  into  the  bladder  and  showed  no  remaining  prostatic  enlargement. 
The  wound  was  closed  as  usual  with  double  catheter  drainage  and 
light  gauze  packs  for  the  lateral  cavities.  The  patient  stood  the  operation 
well,  the  pulse  at  the  end  was  90.  On  return  to  ward  an  infusion  was 
given  and  continuous  intravesical  irrigation  was  begun. 

Convalescence. — The  patient  reacted  well.  The  temperature  reached  101° 
on  the  day  after  the  operation,  but  was  normal  after  the  second  day. 
Gauze  was  removed  in  24  hours  and  the  irrigation  stopped.  The  tubes  were 
removed  the  next  day,  and  the  patient  was  up  in  a  chair.  He  began  to 
walk  about  the  ward  on  the  fourth  day.  Interval  urination  was  established 
after  the  removal  of  the  tubes,  at  first  every  hour,  but  the  interval 
rapidly  increased.  On  the  seventh  day  urine  came  through  the  penis  and 
the  fistula  closed  on  the  18th  day.  Broke  open  two  days  later.  The 
patient  was  discharged  on  the  26th  day.  There  was  still  a  pin  point  fistula. 
Patient  had  no  incontinence,  was  able  to  hold  urine  for  five  hours,  and 
suffered  no  pain.  A  small  silver  catheter  passed  with  ease  and  found  30  cc. 
residual  urine.  The  fistula  was  curetted  and  the  patient  instructed  to 
take  urotropin,  lithia  water  in  abundance  and  to  retain  urine  as  long 
as  possible  to  distend  the  bladder.     (The  fistula  closed  on  the  46th  day.) 

Novemier  30,  1905. — Letter.  The  fistula  closed  soon  after  my  return. 
I  have  had  no  instrumentation.  Void  urine  once  at  night  and  four  times 
during  the  day.  Micturition  is  normal,  I  have  no  pain  and  I  consider 
myself  cured.  Erections  occur  occasionally  and  intercourse  is  satisfactory. 
May  8,  1906. — Letter.  I  void  urine  at  natural  intervals,  suffer  no  pain. 
I  have  no  erections.  My  general  health  is  excellent.  I  consider  myself 
cured. 

Pathological  report. — The  specimen,  G.  U.  144,  consists  of  the  median  and 
lateral  lobes  of  the  prostate  removed  in  three  pieces,  and  weighing  G-43. 


study  of  14-5  Cases  of  Perineal  Prostatectomy.  381 

The  median  lobe  is  composed  of  irregular  lobules  and  measures  5  x  2.5  x  1.5 
cm.  The  right  lobe  measures  5  x  3  x  2.5  cm.  The  left  lobe  5x3x2  cm. 
The  consistence  is  everywhere  elastic,  and  on  section  shows  typical  adeno- 
matous spheroids. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  glandular  one. 
The  acini  show  the  usual  dilatation  with  occasional  cystic  degeneration. 
The  epithelium  lining  the  acini  is  usually  two  layers  in  thickness  al- 
though occasionally  one  sees  solid  epithelial  cones  many  layers  in  depth, 
and  again  slender  bands  of  connective  tissue  growing  into  other  epithelial 
masses  which  would  seem  to  represent  new  glands  in  the  process  of 
formation.  This  picture  is  frequently  seen  in  these  glandular  prostates. 
The  stroma  is  rather  loose,  and  contains  considerable  new  connective 
tissue,  even  in  areas  where  there  is  no  inflammatory  infiltration  and  even 
where  there  is  no  prostatitis  in  the  immediate  neighborhood.  There  is  a 
fair  amount  of  muscle  present,  and  some  areas  of  chronic  prostatitis. 

Case  79. — Considerable  hypertrophy  of  lateral  lobes.  Small  median  bar. 
Intermittent  attacks  of  great  frequency  and  difficulty  of  urination.  Cure. 
Followed  14  months. 

No.  879.    A.  H.  L.,  age  68,  widowed,  admitted  March  25,  1905. 

Complaint. — "  Diflaculty  in  passing  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  about  five  years  ago  with  slight  difficulty  and 
frequency  of  urination.  This  had  gradually  increased  until  the  patient 
now  voids  every  half  hour  during  the  morning,  but  during  the  rest  of  the 
day  he  is  fairly  comfortable  and  at  times  in  the  afternoon  he  will  not 
urinate  for  three  hours  and  as  a  rule  only  gets  up  once  at  night.  Urine 
is  passed  only  after  considerable  straining  and  the  stream  is  small.  He 
has  been  catheterized  several  times,  but  never  on  account  of  retention. 
Two  years  ago  he  had  hematuria  lasting  24  hours,  and  several  months 
later  a  similar  attack,  but  there  was  no  pain  in  the  kidney,  bladder,  or 
penis.  He  has  not  lost  weight,  his  erections  are  fairly  good,  but  he  has  not 
had  intercourse  for  years. 

S.  P. — The  patient  urinates  at  intervals  varying  from  two  to  four  hours, 
but  occasionally  there  are  periods  during  which  urination  is  very  frequent 
and   the  bladder  very  irritable.     He  usually   arises   only  once   at  night. 

Examination. — The  patient  is  sturdy  in  appearance  and  his  lips  are  of 
good  color.  Chest  and  abdomen  negative.  A  large  right  inguinal  hernia 
is  present.    The  testicles  and  epididymis  are  normal. 

Rectal  examination. — The  prostate  is  considerably  enlarged  particularly 
in  its  transverse  diameter  which  is  at  least  twice  as  great  as  normal.  The 
median  furrow  is  wide  and  the  notch  is  fairly  deep.  The  surface  is  smooth, 
rounded,  elastic,  the  seminal  vesicles  are  not  indurated. 

Urine. — Cloudy,  alkaline,  1020.  Albumin  moderate.  Microscopically, 
pus  cells,  no  bacteria  seen. 

Cystoscopic  examination. — A  small  coude  catheter  passes  and  meets  with 
-considerable  obstruction  before  entering  the  bladder.    Only  25  cc.  residual 


322  Hugh  H.  Young. 

urine  present.  Bladder  capacity  is  240  cc,  the  tonicity  is  good.  The  cys- 
toscope  shows  a  medium  sized  sessile  middle  lobe  with  a  shallow  sulcus 
on  each  side.  The  lateral  do  not  project  much  into  the  bladder  and  there 
is  no  cleft  between  them  in  front.  With  the  finger  in  the  rectum  and 
cystoscope  in  the  urethra  a  considerable  increase  in  the  median  portion 
of  the  prostate  is  made  out.    There  was  no  foreign  body  present. 

Operation,  March  30,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  of  considerable  size  and  easily  enucle- 
ated. The  median  lobe  was  drawn  down  into  the  left  lateral  cavity  without 
injury  of  the  urethra,  bladder  or  ejaculatory  ducts.  The  middle  lobe  was 
about  2y2  cm.  in  diameter.  Owing  to  the  absence  of  cystitis  the  operator 
did  not  insert  a  catheter  into  the  bladder,  but  packed  the  lateral  cavities 
lightly  ■  with  gauze.  The  patient  was  infused,  and  the  wound  closed  as 
usual.    The  patient  stood  the  operation  well. 

Convalescence. — There  was  more  hemorrhage  than  usual  during  the  night 
after  the  operation,  but  the  pulse  which  was  74  at  the  end  of  the 
operation  did  not  go  above  84  during  the  night.  The  gauze  was  removed 
16  hours  after  the  operation,  at  that  time  hemorrhage  had  ceased  and 
condition  of  the  patient  was  excellent.  The  patient  was  up  in  a  wheel  chair 
on  the  fourth  day  and  on  this  day  the  urine  began  to  come  through  the 
penis,  but  the  fistula  did  not  close  finally  until  the  20th  day.  Immediately 
after  the  operation  the  patient  was  able  to  retain  urine  for  a  definite 
interval.  Since  then  the  time  between  urinations  has  increased  and  on 
the  21st  day  he  was  voiding  urine  every  five  hours.  There  was  no 
incontinence  but  urination  was  often  urgent,  and  the  sphincter  weak,  so 
that  when  he  coughs  a  few  drops  may  escape.  Erections  returned  two 
weeks  after  the  operation.  He  was  discharged  from  the  hospital  on  the 
28th  day.  The  wound  healed.  Voiding  urine  every  five  hours  without 
pain  and  with  good  force.  The  urine  before  operation  was  clear,  1020, 
contained  albumin  and  a  few  pus  cells,  but  no  bacteria. 

On  the  15th  day  the  patient  developed  fever  without  explainable  cause. 
There  was  no  epididymitis,  no  renal  or  lung  complication.  It  began  with 
a  temperature  of  102.5°,  but  after  three  days  it  was  almost  normal. 

July  20,  1905. — Report  by  his  physician.  This  case  has  been  eminently 
satisfactory.    There  is  no  cystitis,  no  fistula. 

November  30,  1905. — Letter.  Urine  passes  without  difficulty,  several 
times  during  the  day  and  once  at  night.  I  have  no  pain,  but  there  is 
still  sensitiveness  in  the  bladder  and  occasionally  I  have  to  void  urine 
three  times  at  night  on  this  account.  Erections  have  returned.  My  general 
health  is  excellent  and  I  have  gained  in  weight. 

May  21,  1906. — Letter.  I  void  urine  naturally  at  intervals  of  from  three 
to  five  hours,  and  frequently  none  at  all  at  night.  I  suffer  no  pain, 
erections  have  returned.  I  have  had  no  complications  and  no  treat- 
ment. My  general  health  is  good,  and  I  consider  the  operation  entirely 
satisfactory. 

Pathological  report. — The  specimen,  G.  U.  146,  consists  of  four  pieces 


study  of  IJfO  Cases  of  Perineal  Prostatectomy.  323 

and  vreighs  about  G-55.  The  median  lobe  is  in  the  shape  of  a  globular 
mass  about  2%  cm.  in  diameter  with  a  smooth  outer  surface.  On  section 
it  shows  considerable  gland  tissue  with  little  stroma.  The  left  lateral  lobe 
has  been  removed  in  one  piece,  and  measures  about  4x4x3  cm.  TTie 
surface  is  fairly  smooth,  encapsulated.  On  section  there  is  considerable 
stroma  and  many  dilated  acini.  The  right  lobe  has  been  removed  in  two 
pieces,  both  of  which  are  considerably  torn.  It  presents  a  similar  appear- 
ance to  the  left.  No  mucous  membrane,  no  ejaculatory  ducts  are  present, 
no  calculus  present. 

Microscopic  examination. — Microscopically  the  tissue  is  a  moderately 
glandular  one  with  the  formation  of  spherical  lobules.  There  is  a  consid- 
erable, amount  of  stroma  present.  Within  the  lobulated  areas  the  stroma 
is  more  evident  than  one  sees  in  manj^  of  these  similar  hypertrophies. 
The  acini  are  moderately  dilated  and  in  areas  there  is  fairly  well  marked 
cystic  degeneration.  The  stroma  contains  much  more  fibrous  tissue  than 
muscle.  In  the  interlobular  areas  the  stroma  is  more  abundant,  but  there 
is  present  a  fair  amount  of  glandular  element.  Some  areas  of  small  round 
cell  infiltration  are  seen.  Numerous  corpora  amylacea  are  present  in  the 
ducts.     The  arteries  are  apparently  not  undergoing  any  sclerotic  changes. 

Case  80. — Large  hypertrophy  of  median  and  lateral  lobes.  Emphysema 
of  lungs,  cardiac  murmur.    Casts  in  urine.    Cure.    Followed  13  months. 

No.  1331.     J.  M.,  age  65,  single,  admitted  March  5,  1905. 

Complaint. — ^"  Retention  of  urine." 

Patient  had  gonorrhoea  at  the  age  of  24  and  again  at  the  age  of  34.  No 
epididymitis  with  either  attack. 

Present  illness.— ^Fov  15  years  the  patient  has  had  a  slight  increased  fre- 
quency of  urination,  but  no  dysuria.  In  October,  1903,  he  had  complete 
retention  of  urine  requiring  catheterization.  After  this  he  remained  fairly 
well  but  for  frequency  of  urination  until  one  week  ago.  Since  then  he 
has  been  unable  to  void  and  has  been  catheterized  twice  a  day  with  ex- 
treme difficulty.     He  is  weak  and  has  lost  weight. 

Sexual  powers. — ^Normal. 

Examination. — 'The  patient  is  sturdy,  his  lips  are  of  good  color. 

Lungs. — Everywhere  hyperresonant,  mucous  rales  over  both  bases. 
Heart  negative  except  slight  presystolic  rumble  at  apex.  The  abdomen  is 
negative. 

Rectal. — iProstate  is  considerably  and  symmetrically  enlarged,  smooth, 
elastic.  There  is  no  induration  in  the  region  of  the  seminal  vesicles,  no 
tenderness. 

Cystoscopic. — ^The  patient  was  able  to  void  15  cc.  and  was  catheterized 
immediately  afterward,  residual  urine  240  cc,  bladder  capacity  300  cc. 
The  cystoscope  shows  a  large  globular  median  lobe  with  a  deep  sulcus  on 
each  side.  The  lateral  lobes  are  very  little  intravesically  hypertrophied 
and  there  is  no  sulcus  between  them  in  front.  With  finger  in  rectum  and 
cystoscope  in  urethra  there  is  considerable  increase  in  the  median  portion. 

Preliminary  treatment. — Continuous  drainage  through  a  permanent  cath- 


334  Hugh  H.  Young. 

eter,  vesical  irrigations,  urotropin,  large  amounts  of  water  by  mouth. 
Under  this  treatment  the  urea  increased  from  28  gm.  to  36  gm.,  and  the 
total  solids  from  44  gm.  to  52  gm.  The  urine  contained  pus  cells,  a  few 
hyaline  casts.    Sp.  gr.  1015  to  1025,  albumin  a  trace. 

Operation,  April  6,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  measured  3x4x6  cm.  in  size  were 
each  removed  in  one  piece  without  tearing  the  mucous  membrane.  A 
small  portion  of  the  median  lobe  was  removed  with  the  right  lateral  lobe. 
Most  of  the  median  lobe  was  found  drawn  well  down  along  the  urethra 
by  the  tractor  by  the  rotation  and  traction  on  the  instrument.  It  was  very 
adherent  to  the  mucous  membrane  and  a  small  area  of  this  was  removed 
adherent  to  the  lobe.  Examination  with  the  finger  showed  no  remaining 
enlargement.  The  wound  was  closed  as  usual  with  double  tube  drainage 
and  light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation 
well,  pulse  at  end  90.  Continuous  irrigation  and  infusion  on  return  to 
the  ward. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
on  the  fourth  day  after  the  operation,  102°,  after  that  practically  normal. 
The  gauze  and  catheters  were  removed  on  the  day  after  the  operation,  and 
the  patient  was  up  in  a  wheel  chair  the  next  day  and  walked  on  the  third 
day.  On  the  fifth  day  a  very  slight  epididymitis  developed  on  the  right 
side  which  disappeared  quickly  under  ice  bag  treatment.  The  temperature 
did  not  remain  elevated  for  more  than  two  days.  The  urine  did  not  flow 
through  the  anterior  urethra  until  the  17th  day,  and  the  patient  was  dis- 
charged on  the  20th  day.  The  wound  had  healed  per  primam,  there  was  a 
pin  point  fistula  through  which  only  a  few  drops  of  urine  escaped,  and  he 
was  able  to  retain  urine  for  four  hours  and  suffered  no  pain.  General  con- 
dition excellent.     The  fistula  finally  closed  on  the  25th  day. 

February  20,  1906. — Letter.  The  wound  has  remained  healed,  I  void  just 
like  a  boy,  have  no  dribbling.  Urinate  at  intervals  of  five  or  six  hours 
in  the  day  and  six  or  seven  hours  in  the  night.  I  suffer  no  pain.  Erec- 
tions have  returned  and  sexual  intercourse  is  normal  and  entirely  satisfac- 
tory. Ejaculations  profuse.  I  have  had  no  complications  and  my  health  is 
fine. 

May  6,  1906. — Letter.  I  void  urine  naturally  at  normal  intervals,  about 
six  ounces  at  a  time.  I  have  no  pain.  I  have  erections  and  satisfactory 
intercourse,  the  act  being  the  same  as  before  operation.  My  general  health 
is  good,  I  have  gained  40  pounds  and  I  consider  myself  cured. 

Pathological  report. — -The  specimen,  G.  U.  147,  consists  of  the  three  lobes 
of  the  prostate  removed  each  in  one  piece  and  weighs  about  20  gm.  The 
right  lobe  measures  4  x  2.5  x  2  cm.,  is  fairly  smooth,  elastic,  and  on  section 
shows  a  little  capsule,  fairly  homogeneous  surface  with  few  spheroids,  few 
dilated  acini  and  little  stroma.  The  left  lobe  is  about  the  same  size  as  the 
right,  but  seems  to  contain  more  stroma.  The  median  lobe  measures  3  x 
2  X  1.5  cm.,  and  is  similar  in  appearance  to  the  others.  No  mucous  mem- 
brane, no  ejaculatory  ducts,  no  calculi. 

Microscopic  examination. — In  the  right  lateral  the  tissue  contains  very 


study  of  145  Cases  of  Perineal  Prostatectomy.  325 

distinct  lobules  which  are  mostly  composed  of  adenomatous  tissue,  and 
between  these  lobules  are  bands  containing  a  fair  number  of  glandular 
culs-de-sac.  The  acini  within  the  lobules  show  considerably  more  dilata- 
tion and  evidence  of  glandular  proliferation  than  do  the  acini  in  the 
stroma  outside.  In  the  interstitial  tissue  between  these  glandular  lobules 
there  is  a  very  marked  prostatitis  present,  the  lumina  of  the  culs-de-sac 
being  often  filled  with  leucocytes  and  epithelial  cells.  The  inflammatory 
infiltration  in  places  is  almost  of  sufficient  density  to  suggest  abscess 
formation.  The  prostatitis,  however,  does  not  seem  to  have  invaded  these 
glandular  lobules,  although  they  are  surrounded  on  all  sides  by  the  in- 
flammatory processes. 

The  left  lobe  is  distinctly  less  glandular  than  the  right,  and  there  seems 
to  be  no  formation  of  spherical  lobules.  There  is  everywhere  present  a 
diffuse  prostatitis,  the  ducts  being  filled  with  leucocytes  and  epithelial 
cells  and  the  interstitial  tissue  infiltrated. 

The  picture  in  the  left  lobe  is  almost  purely  one  of  prostatitis  with 
very  little  evidence  of  gland  proiferation. 

Case  81. — Moderate  hypertrophy.  Two  calculi.  Incomplete  retention. 
Cure. 

No.  888.    C.  A.,  age  62,  married,  admitted  April  11,  1905. 
Complaint. — "  Bladder  trouble." 

Gonorrhoea  at  the  age  of  32,  followed  by  gleet,  no  stricture. 
Present  illness  began  12  years  ago  with  a  sudden  attack  of  retention  of 
urine,  requiring  catheterization  for  two  days.  After  that  the  course  of 
the  disease  was  characterized  by  gradual  increase  in  difficulty  and  fre- 
quency which  has  been  considerably  worse  during  the  past  few  years — ^no 
pain,  but  occasionally  slight  hematuria. 

8.  P. — ^Urination  every  hour  during  the  night,  every  one  and  one-half 
hour  during  the  day.  For  the  past  two  months  there  has  been  a  slight 
pain  during  urination,  and  occasionally  hemorrhage. 

Sexual  powers. — ^Erections,  ejaculations  and  coitus  normal. 
Examination. — Patient  is  a  sturdy  looking  man.     Chest  and  abdomen 
negative. 

Rectal. — The  prostate  is  enlarged,  but  only  moderately.  It  is  smooth, 
elastic,  fairly  firm.  The  median  furrow  is  shallow  and  the  notch  absent. 
At  the  upper  end  of  the  right  lateral  lobe  is  a  small,  hard,  round  mass 
which  projects  upward  towards  the  seminal  vesicle  which  is  not  indurated. 
The  left  seminal  vesicle  was  also  normal,  and  there  are  no  adhesions. 

Urinalysis. — Very  cloudy,  alkaline,  sp.  gr.  1015,  no  sugar,  albumin  in 
moderate  amount.  Urea  10  gm.  to  the  liter.  Microscopically,  bacilli,  cocci 
and  pus  cells. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  150  cc.  resid- 
ual urine.  The  bladder  is  contracted  and  holds  only  250  cc.  The  cysto- 
scope  shows  very  little  enlargement  of  the  lateral  lobes,  but  a  distinct, 
though  small,  median  enlargement  with  a  sulcus  on  each  side.  The  mu- 
cous membrane  covering  the  median  lobe  is  extremely  red  and  two  large 


326  Hugh  H.  Young. 

granulations  are  seen  on  its  apex.  Tlie  bladder  is  markedly  trabeculated, 
and  contains  two  small  oval,  white  calculi.  No  diverticula  seen.  With 
finger  in  rectum  and  cystoscope  in  urethra,  the  beak  of  the  instrument 
is  indistinctly  felt,  the  median  portion  of  the  prostate  is  considerably  in- 
creased. 

Operation,  April  11,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Removal  of  two  calculi  through  wound.  The  lateral  lobes 
which  were  easily  enucleated  were  only  moderately  enlarged.  A  large  me- 
dian lobe  about  the  size  of  a  walnut  was  enucleated  through  one  of  the 
lateral  cavities.  The  urethra  was  then  divided  longitudinally  along  the 
left  lateral  wall,  the  neck  of  the  bladder  dilated,  forceps  inserted  and  two 
calculi  removed  without  crushing;  no  additional  calculi  were  found. 

The  wound  was  closed  as  usual  with  double  catheter  drainage  and  light 
packs  for  the  lateral  cavities.  Infusion  and  continuous  irrigation  on  re- 
turn to  ward.    Pulse  at  end  of  operation  was  95. 

Convalescence. — iThe  patient  reacted  well,  the  temperature  rising  on  the 
second  day  to  100.6°,  but  normal  after  the  second  day.  The  continuous 
irrigation  was  discontinued  after  14  hours,  gauze  was  removed  in  24  hours, 
the  tubes  in  48.  Urine  passed  through  the  anterior  urethra  on  the  third 
day,  and  the  fistula  closed  on  the  25th  day.  He  left  the  hospital  on  the 
30th  day  in  good  condition,  able  to  retain  urine  for  four  hours  during  the 
day  and  voiding  only  twice  during  the  night.  No  incontinence,  stream 
large.  Silver  catheter  passed  with  ease  and  found  no  residual  urine.  No 
complications  after  the  operation. 

Letter  from  physician. — ^Our  patient  holds  his  water  for  six  hours  and 
is  in  excellent  shape,  but  complains  of  considerable  "  smarting  "  at  times. 
He  passed  concretions  the  size  of  a  pea  two  or  three  weeks  ago. 

Letter  from  physician. — Patient  has  continued  to  have  pain  at  the  end 
of  urination,  and  on  examination  with  the  searcher  I  find  a  calculus.  What 
operation  would  you  advise?     (Suprapubic  lithotomy  was  advised.) 

August  15,  1905. — Operation  by  his  physician.  Suprapubic  cystotomy, 
removal  of  a  calculus  one  inch  in  diameter,  closure  of  bladder  with  catgut. 
The  prostatic  orifice  was  examined  with  a  finger  in  the  bladder  and  pre- 
sented a  normal  appearance. 

Convalescence. — 'The  suprapubic  wound  leaked  slightly  on  the  seventh 
day,  but  after  the  tenth  day  there  was  no  leakage.  He  had  no  complica- 
tions. 

February  12,  1906. — 'Letter  from  physician.  Both  wounds  are  closed. 
Urine  is  voided  naturally,  he  is  able  to  retain  it  from  six  to  eight  hours 
and  does  not  get  up  at  night.  He  has  no  pain.  Sexual  powers  are  normal, 
and  intercourse  the  same  as  before  operation.    His  general  health  is  good. 

May  10,  1906. — 'Letter.  I  void  urine  naturally  three  or  four  times  a  day 
and  twice  at  night,  half  a  pint  at  a  time.  I  suffer  no  pain.  Have  erec- 
tions and  satisfactory  intercourse.  My  general  health  is  excellent,  and  I 
consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  148,  consists  of  the  three  lobes 
of  the  prostate  each  removed  in  one  piece  and  weighs  about  30  gm.    The 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  327 

left  lobe  measures  5x1x3  cm.,  is  somewhat  irregular,  and  on  section 
shows  considerable  stroma,  and  only  a  moderate  amount  of  gland  tissue. 
The  right  lobe  measures  6  x  3  x  1.5  cm.,  and  is  similar  in  character  to  the 
left.  The  median  lobe  measures  6.5  x  3  x  3  cm.,  and  in  its  lower  portion 
presents  a  small  round  nodule  about  1.5  cm.  in  diameter  which  was  dis- 
tinctly suburethral.  On  section  there  is  considerable  gland  tissue  and  a 
small  amount  of  stroma.  No  mucous  membrane,  no  ducts.  Two  stones, 
each  measuring  6.5  x  3.5  x  1.5  cm.  have  been  removed. 

Microscopic  examination. — The  middle  and  left  lobes  show  stroma 
and  gland  tissue  in  about  equal  proportions.  The  gland  tissue 
is  aggregated  in  areas  with  rather  broad  bands  of  stroma  intervening. 
Within  the  glandular  areas  the  acini  are  moderately  dilated  with  an 
occasional  cystic  degeneration  of  an  acinus.  As  a  rule  the  acini 
show  considerable  complexity  due  to  intraacinous  proliferation.  The 
acini  within  the  broad  bands  of  stroma  are  as  a  rule  much  compressed. 
The  stroma  contains  a  fair  amount  of  muscle.  The  right  lobe  has  dis- 
tinctly less  gland  tissue  than  either  of  the  other  lobes,  and  there  is  present 
quite  a  marked  prostatitis  with  the  formation  of  considerable  inflammatory 
tissue  and  atrophy  of  acini.  The  fibro-muscular  type,  as  a  whole,  pre- 
dominates, although  richly  glandular  areas  are  present. 

Case  82. — Severe  stricture  of  urethra,  involving  prostate,  complete  re- 
tention of  urine  and  catheter  life  for  eight  years.  Multiple  diverticula. 
Prostatectomy,  urethrotomy.     Cure. 

No.  848.     J.  P.  C,  age  54,  married,  admitted  March  18,  1905. 

Complaint. — "  Stricture  of  urethra.  Complete  retention  of  urine.  Cath- 
eterism." 

Twelve  years  before,  the  patient  had  had  gonorrhoea,  which  was  fol- 
lowed by  a  stricture  which  gradually  became  worse,  urination  more  diffi- 
cult, and  eight  years  ago  complete  retention  of  urine.  Under  chloroform  a 
sound  was  forcibly  passed  into  his  bladder  and  a  false  passage  produced. 
Since  then  he  has  never  been  able  to  void  urine  and  has  had  to  lead  a 
catheter  life.  During  this  time  he  has  had  several  operations  performed 
for  the  stricture.  Internal  urethrotomy,  external  urethrotomy  and  fre- 
quent dilatation,  but  at  no  time  has  he  been  able  to  void. 

S.  P. — He  now  catheterizes  himself  with  a  small  silver  catheter  every 
three  hours  night  and  day.  Sexual  powers  are  normal.  General  health 
good. 

Examination. — 'The  patient  is  a  well  nourished  man  with  lips  of  good 
color.  Chest  and  abdomen  negative.  The  right  testicle  is  markedly  atro- 
phic. 

Rectal. — ^Slight  hemorrhoids  are  present.  Prostate  is  normal  in  size 
and  consistence,  with  exception  of  the  upper  portion  of  the  left  lateral 
lobe  in  which  there  is  an  induration  which  extends  upward  and  involves 
the  left  seminal  vesicle  and  vas.  On  the  right  side  there  is  a  small  nodule 
at  the  junction  of  the  vesicle  and  prostate. 

Urethral. — In  the  bulbo-membranous  portion  of  the  urethra  there  is  a 


338  Hugh  H.  Young. 

hard  stricture  whicli  will  not  admit  a  No.  24  F.  sound,  a  filiform  and  fol- 
lowers are  passed,  but  are  tightly  grasped  in  the  membranous  and  pros- 
tatic urethra.  A  small  silver  catheter  now  passes  with  ease,  and  finds  a 
bladder  capacity  of  270  cc.  The  cystoscope  shows  an  enlargement  of  each 
lateral  lobe,  but  the  enlargement  is  almost  entirely  intraurethral,  pre- 
senting as  two  lateral  intraurethral  rounded  lobules  with  a  small  trans- 
verse median  fold  behind  them,  as  shown  in  the  cystoscopic  charts  in  ar- 
ticle on  cystoscopy  of  the  prostate.  Case  XXI.  The  bladder  is  markedly 
trabeculated  and  the  orifices  of  five  diverticula  are  seen.  With  finger  in 
rectum  and  cystoscope  in  urethra  there  is  very  little  increase  in  the  median 
portion  of  the  prostate. 

Urinalysis. — ^^Neutral,  1020,  no  sugar,  trace  of  albumin,  urea  15  gm.  to 
liter.    Microscopically,  pus  and  bacilli. 

Remark. — -Urethral  and  rectal  examination  seem  to  show  that  the  ob- 
struction was  due  to  a  stricture  of  the  urethra,  but  internal  and  external 
urethrotomy  and  frequent  dilatations  of  the  urethra  had  failed  to  restore 
even  temporarily  the  power  of  urination.  It  seemed  evident  therefore  that 
the  interurethral  prostatic  lobules  were  the  cause  of  the  complete  reten- 
tion of  urine,  and  perineal  prostatectomy  was  therefore  advised. 

Operation,  April  12,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Longitudinal  division  of  extensive  stricture  of  bulbo-mem- 
branous  urethra.  An  inverted  Y  incision  was  made.  The  bulb  of  the  ure- 
thra was  exposed  and  found  to  be  very  greatly  indurated  and  the  mem- 
branous urethra  was  surrounded  by  a  considerable  amount  of  fibrous  tis- 
sue, and  the  rectum  was  so  closely  adherent  that  it  had  to  be  dissected 
free  with  great  care.  The  membranous  urethra  is  opened  upon  a  small 
staff,  but  it  was  impossible  to  insert  a  sound  until  it  had  been  dilated  with 
forceps.  The  lateral  lobes  were  very  little  enlarged,  very  adherent,  and 
the  sharp  periosteal  elevator  had  to  be  used  in  freeing  them  from  the 
vesical  mucosa.  The  median  bar  was  removed  in  two  pieces  through  the 
left  lateral  cavity  with  scissors.  Examination  with  the  finger  after  re- 
moval of  the  tractor  showed  no  remaining  enlargement,  and  the  large  di- 
verticulum back  of  the  left  ureter  easily  admitted  the  finger.  Double 
catheter  drains  and  lateral  gauze  packs  were  then  inserted  and  attention 
then  directed  to  strictured  membranous  and  bulbous  urethra,  which  were 
opened  longitudinally  upon  a  grooved  sound.  The  urethra  was  found  to 
be  surrounded  by  dense  fibrous  tissue  from  5  to  8  mm.  thick.  The  bulb 
was  completely  transformed  to  fibrous  tissue,  and  did  not  bleed.  The  mu- 
cous membrane  of  the  urethra  was  white  and  looked  like  skin.  The  su- 
perior wall  of  the  urethra  was  also  divided  along  the  strictured  region. 
Pack  was  then  placed  into  the  urethral  wound  and  the  lateral  branches  of 
the  incision  were  closed  with  catgut.  The  patient  stood  the  operation  well. 
His  pulse  at  the  end  was  105.  His  condition  excellent.  Salt  solution  and 
continuous  irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well,  but  on  the  day  after  the  op- 
eration the  temperature  rose  to  104°,  but  two  days  later  returned  to  nor- 
mal, and  after  that  there  was  very  little  rise.    The  continuous  irrigation 


study  of  lJ/5  Cases  of  Perineal  Prostatectomy.  329 

was  stopped  at  the  end  of  12  hours,  the  gauze  removed  within  24  hours, 
and  the  tubes  in  48  hours.  Urine  first  passed  through  the  anterior  urethra 
on  the  18th  day  and  the  fistula  closed  on  the  30th  day.  Interval  urination 
was  established  immediately  after  the  removal  of  the  tubes  on  the  second 
day,  and  on  his  discharge  from  the  hospital  on  the  40th  day,  he  was  able 
to  retain  urine  for  four  hours,  voided  with  a  large  strong  stream,  and  had 
no  pain.  An  attempt  was  made  to  pass  a  catheter,  but  it  was  caught  in  a 
pocket  in  the  bulbous  urethra.  Filiforms  were  arrested  in  the  prostatic 
urethra. 

May  26,  1905. — A  filiform  passed  easily  to-day  and  the  urethra  is  dilated 
up  to  22  F. 

June  6,  1905. — The  patient  was  dilated  several  times  with  filiforms  and 
followers.  The  Kollmann  dilator  passed  with  ease  and  can  be  dilated  up 
to  27  F. 

Cystoseopic  examination. — A  catheter  passes  with  ease  and  finds  only 
20  cc.  residual  urine.  The  cystoscope  shows  no  prostatic  enlargement.  The 
diverticula  are  still  present.  The  patient  voids  urine  in  a  full  stream,  has 
no  incontinence,  partial  erections  have  occurred. 

Novemher  30,  1905. — Letter.  The  wound  has  remained  closed.  I  have 
had  no  dilatation  or  other  treatment.  I  void  urine  naturally,  four  times 
during  the  day  and  twice  at  night,  sometimes  one  pint  at  a  time.  Erections 
have  returned  and  intercourse  is  entirely  satisfactory.  My  general  health 
is  good  and  I  consider  myself  cured. 

May  9,  1906. — Letter.  I  void  urine  normally  at  natural  intervals  and  in 
normal  quantities.  I  suffer  no  pain.  I  have  erections  and  satisfactory  in- 
tercourse. My  general  health  is  fine  and  I  have  gained  in  weight,  and  I 
consider  myself  cured. 

PatJiological  report. — The  specimen,  G.  U.  149,  consists  of  three  lobes 
of  the  prostate,  and  weighs  about  12  gm.  The  right  lobe 
measures  5  x  1.5  x  2  cm.,  is  irregular  in  shape,  and  on  section 
shows  considerable  stroma,  and  no  dilated  acini.  The  left  lobe  is  more 
regular,  measures  5  x  3.5  x  1.5  cm.,  and  on  section  shows  a  great  deal  of 
stroma  and  is  very  fibrous  in  feel.  The  median  portion  is  represented  by 
a  mass  8  mm.  in  diameter  and  seems  very  fibrous  in  character.  No  mu- 
cous membrane,  no  ejaculatory  ducts,  no  calculus  removed. 

Microscopic  examination. — On  microscopic  examination  the  hyper- 
trophy in  the  right  lobe  is  of  a  fibro-muscular  type  with  a 
moderate  amount  of  gland  acini  present.  The  acini  are  for 
the  most  part  arranged  in  small  aggregations,  and  the  lumina  are 
nearly  all  small.  Only  occasionally  does  one  see  any  complexity  of  the 
lumina  and  scarcely  any  evidence  of  glandular  proliferation  is  present. 
There  is  no  evidence  of  compression  due  to  formation  of  inflammatory  tis- 
sue. The  stroma  is  considerably  in  excess  of  the  gland  tissue,  and  seems 
to  contain  slightly,  more  muscle  than  connective  tissue,  the  muscle  and 
connective  tissue  interlacing  in  various  ways.  In  the  left  lobe  the  stroma 
and  gland  tissue  are  present  in  the  same  proportion  as  in  the  right,  but 
the  acini  in  a  few  areas  show  more  signs  of  glandular  proliferation,  and 
Vol.  XIV.— 22. 


330  Hugh  H.  Young. 

also  have  more  complexity  of  their  lumina.  The  stroma  is  very  rich  in 
muscle.  There  is  present  a  well  marked  prostatitis,  especially  marked  in 
the  pei'iglandular  tissue. 

Case  83. — Considerable  enlargement  of  lateral  lobes.  Small  median  bar. 
Previous  suprapubic  prostatectomy.  Vesical  calculi.  Old  endocarditis. 
Reacted  well.  Hiccough,  stupor.  Hypostatic  congestion  of  lungs.  Death 
21st  day. 

No.  899.     W.  S.  H.,  age  73,  married,  admitted  April  17,  1905. 

Complaint. — "  Inability  to  urinate.     Catheterism." 

History  of  probable  gonorrhoea  at  age  of  17  years. 

Present  illness  began  about  15  years  ago  with  frequency  and  difficulty  of 
urination.  During  the  next  three  years  there  was  a  gradual  increase  in 
difficulty  and  frequency,  and  then  complete  retention  of  urine  came  on,  re- 
quiring catheterization.  After  that  urination  was  very  frequent,  but  the 
catheter  was  not  used  until  four  years  ago,  but  catheterization  was  very 
difficult,  and  suprapubic  prostatectomy  was  performed  by  another  surgeon. 
The  suprapubic  wound  healed  and  micturition  was  improved,  but  still  fre- 
quent for  a  time,  but  he  soon  had  to  begin  the  use  of  the  catheter  again, 
and  during  the  past  year  has  led  a  catheter  life. 

8.  P. — The  patient  catheterizes  himself  five  or  six  times  in  24  hours. 
Of  late  he  has  had  considerable  pain  in  the  region  of  the  bladder,  but  no 
hematuria.  His  general  health  has  been  bad,  and  he  has  lost  considerable 
weight,  having  lost  20  pounds  during  the  past  year. 

Sexual  powers  have  been  practically  absent  for  several  years. 

Examination. — (The  patient  is  a  well  nourished  old  man.  Radial  arteries 
are  moderately  sclerotic.  Pulse  is  regular  and  of  good  quality,  about  80  to 
the  minute. 

Chest. — iThe  lungs  are  clear  throughout,  but  hyperresonant. 

Heart. — 'The  point  of  maximum  impulse  is  in  the  fourth  interspace  about 
1  cm.  outside  of  the  nipple  line.  A  systolic  murmur  is  present  at  the  apex 
and  transmitted  to  the  axilla.  There  is  a  systolic  murmur  in  the  pulmonic 
area  and  the  second  pulmonic  and  second  aortic  are  ringing  in  character. 

Abdomen. — ^Three  hernise  are  present.  A  small  ventral  in  the  region  of 
the  suprapubic  scar,  a  small  incomplete  right  inguinal  and  a  very  large 
complete  left  inguinal.     Kidneys  negative. 

Rectal. — "The  prostate  is  considerably  enlarged  in  both  lateral  lobes, 
each  of  which  forms  a  globular  mass  about  the  size  of  a  hen's  egg  with  a 
deep  sulcus  and  notch  between  them.  The  prostate  is  smooth,  symmetri- 
cal, elastic,  but  firm  and  not  nodular.  The  seminal  vesicles  are  negative. 
One  small  shotlike  nodule  is  felt  on  the  left  side,  but  no  enlarged  gland. 

Cystoscope. — A  coude  catheter  passes  with  ease,  retention  of  urine  is 
complete.  Bladder  capacity  370  cc.  The  cystoscope  shows  two  large  intra- 
vesical lateral  lobes  connected  without  intervening  sulci  by  a  median  bar 
of  slight  degree.  There  is  a  deep  cleft  between  the  lateral  lobes  in  front. 
The  bladder  is  moderately  trabeculated  and  considerably  inflamed,  and 
contains  three  small  freely  movable  calculi.     The  ureters  are  easily  seen 


study  of  lli-5  Cases  of  Perineal  Prostatectomy.  331 

and  are  apparently  normal.  With,  finger  in  rectum  and  cystoscope  in  ure- 
thra the  median  portion  of  the  prostate  is  found  only  moderately  enlarged. 

Urinalysis. — Very  cloudy,  acid,  1012,  albumin  in  small  amount,  no  sugar. 
Urea  10.5  gm.  to  the  liter.  Microscopically,  pus  cells  and  numerous  bac- 
teria. 

Preliminary  treatment. — Regular  catheterization,  urotropin  and  water  in 
abundance.  The  patient  was  evidently  a  poor  surgical  risk,  but  owing  to 
the  pain  and  the  frequent  necessity  of  catheterization  and  the  calculi,  op- 
eration was  thought  advisable. 

Operation,  April  24,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  each  enucleated  easily  in  one  piece  and 
measur-ed  each  about  2  x  2V>  x  2  cm.  Examination  showed  very  little  me- 
dian enlargement  and  nothing  was  removed.  In  order  to  remove  the  cal- 
culi the  urethra  was  divided  along  the  left  lateral  wall,  and  the  three  cal- 
culi were  removed,  the  largest  measuring  1  x  1%  cm.  in  size.  The  wound 
was  closed  as  usual  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  Infusion  and  continuous  irrigation  on  return  to  the  ward. 
The  patient  stood  the  operation  well.     Pulse  at  the  end  88. 

Convalescence. — The  patient  reacted  well  from  the  operation,  the  pulse 
varying  between  76  and  84  during  the  next  24  hours.  The  temperature 
rose  to  100.6°.  There  was  practically  no  post-operative  hemorrhage  and 
ver5'  little  vomiting. 

April  25,  1905. — ^Highest  temperature  100.6°,  pulse  88  to  108.  Respira- 
tions 20  to  24.  Continuous  irrigation  discontinued,  gauze  removed,  small 
amount  of  bleeding. 

April  26,  1905.— ^Highest  temperature  100°,  pulse  80  to  104,  respirations 
20  to  24.    Fairly  comfortable,  soft  diet,  water  in  abundance,  tubes  removed. 

April  27,  1905. — Temperature  99°,  pulse  88,  respirations  20.  Light  diet 
and  water  in  abundance.     Complains  of  pain  in  wound. 

April  28.  1905. — Temperature  100.2°,  pulse  96,  respirations  24.  Light 
diet,  water  in  abundance.  Urine  secreted  in  large  amount,  Patient  com- 
plains of  pain  in  wound  and  discomfort  in  abdomen. 

April  29,  1905. — ^Highest  temperature  101.2°,  pulse  96,  respirations  20. 
The  patient  is  drowsy,  weak  and  listless,  has  very  little  appetite. 

April  30,  J905.— Highest  temperature  100.6°,  pulse  88  to  104,  respirations 
20  to  24.  Drowsy,  very  little  appetite,  water  86  ounces  by  mouth.  Infu- 
sion of  1000  cc.  salt  solution. 

May  1,  1905. — ^Patient  had  a  chill  followed  by  a  temperature  of  101.4°. 
Weak,  drowsy,  hiccoughing.  Water  28  ounces  by  mouth,  infusion  1000  cc. 
salt  solution. 

May  2,  i9i9.5.— 'Highest  temperature  99.6°,  condition  improved,  up  in  a 
chair.  Hiccough  at  intervals,  soft  diet,  water  30  ounces  by  mouth,  200  cc. 
by  rectum. 

May  6,  1905.— ^he  patient  has  had  a  daily  temperature,  generally  reach- 
ing 101°,  to-day  99°.  He  has  been  weak,  at  times  irrational  and  hiccough- 
ing intermittently,  his  respirations  have  become  weak  and  there  is  con- 
siderable expectoration. 


332  Hugh  H.  Young. 

May  10,  1905. — iThe  patient  has  had  a  slight  temperature,  has  been  irra- 
tional at  times,  complains  of  considerable  pain  in  the  wound.  No  nausea, 
vomiting  or  hiccough  for  several  days.  Soft  diet  and  water  in  abundance. 
Infusion  1000  cc.  salt  solution  two  days  ago.  Examination  of  the  chest 
showed  many  rales,  and  a  condition  of  hypostatic  congestion. 

May  12,  1905. — 'Patient  is  becoming  weaker,  at  times  in  a  heavy  stupor. 
Respirations  labored,  coughs  considerably,  refuses  nourishment  and  water. 
Temperature  101.6°,  respirations  24. 

May  13,  1905. — The  patient  continues  to  secrete  a  large  amount  of  urine 
and  the  wound  looks  well.  There  is  still  considerable  mucus  in  the  throat, 
the  respirations  are  very  labored,  the  patient  is  in  a  drowsy  state  and 
cannot  be  aroused  and  refuses  nourishment.     Salt  solution  per  rectum. 

May  IJ/,  1905. — The  patient  grew  gradually  weaker  and  more  stupid  and 
respirations  more  shallow  and  rapid,  and  he  died  at  9  p.  m.  During 
the  last  five  days  the  temperature  has  only  reached  102°,  and  the  pulse  has 
not  been  above  110.  There  has  been  no  hiccough,  nausea  or  vomiting  and 
death  has  apparently  been  due  to  hypostatic  congestion  of  the  lungs.  The 
kidneys  continued  to  secret  urine  in  abundance,  and  the  wound  and  blad- 
der appeared  to  do  well.    No  autopsy  was  allt)wed. 

Pathological  report. — ^The  specimen,  G.  U.  159,  consists  of  the  two  lat- 
eral lobes  of  the  prostate  each  removed  in  one  piece  and  weighing  in  all 
about  12  gm.  They  are  about  equal  in  size,  and  measure  2.5  x  2  x  2  cm. 
Their  external  surfaces  are  fairly  smooth,  except  where  torn,  and  on  sec- 
tion the  surface  is  fairly  homogeneous  and  there  are  very  few  dilated 
glands.  A  few  pin-point  calculi  are  scattered  here  and  there.  One  vesical 
calculus  is  whole,  and  measures  1.5  x  1  x  .8  cm.,  and  is  shaped  like  a  beet. 
The  other  calculus  is  about  the  same  size,  but  has  been  broken  into  several 
pieces.  The  outer  surfaces  are  smooth,  white  and  finely  granular.  The 
broken  surfaces  are  yellowish  and  coarsely  granular. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with  the 
arrangement  of  the  acini  in  lobules.  The  acini  are  only  moderately  di- 
lated, and  their  lining  epithelium  shows  considerable  degeneration  and 
desquamation.  In  the  periphery  of  the  lobule  there  is  the  usual  condensa- 
tion of  tissue  with  flattening  and  elongation  of  the  acini.  The  stroma  Is 
largely  composed  of  fairly  dense  connective  tissue,  and  contains  a  rather 
small  amount  of  muscle.    The  arteries  show  but  slight  thickening. 

Case  84. — Moderate  enlargement  of  median  and  lateral  lobes.  Induration. 
Pain,  irritability.    Cure. 

No.  943.     M.  L.  L.,  age  72,  married,  admitted  April  13,  1905. 

Complaint. — "  Enlargement  of  the  prostate.    Frequency  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  about  20  years  ago,  since  which  time  he  has  had 
more  or  less  difficulty  in  urination.  About  this  time  he  had  hematuria 
and  pain  in  the  back  and  diagnosis  of  congestion  of  the  kidneys  was  made. 
He  began  to  get  up  at  night  to  urinate  five  years  ago,  and  since  then  diffi- 
culty and  frequency  have  gotten  gradually  worse. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  333 

jS.  p. — ^He  now  voids  seven  times  during  the  nigM,  and  about  every  hour 
during  the  day.  For  the  past  month  he  has  had  severe  pain  in  the  bladder 
during  urination,  and  occasionally  there  is  considerable  dribbling.  He 
has  no  pain  in  the  back,  perineum  or  thighs.  His  sexual  powers  are  very 
poor.    Erections  few  and  imperfect. 

Examination. — The  patient  is  a  fairly  well  nourished  man.  Chest  and 
abdomen  are  negative. 

Rectal  examination. — The  prostate  is  moderately  hypertrophied.  The 
left  lateral  lobe  is  larger  than  the  right  which  is  small  and  contains  about 
the  middle  of  its  outer  surface  a  small,  round,  hard  nodule  about  the  size 
of  a  pea.  The  rest  of  the  prostate  is  soft  and  there  is  no  induration  in  the 
region  of  the  seminal  vesicles,  no  enlarged  glands.  The  urine  is  very 
cloudy  and  contains  a  large  amount  of  pus  and  cocci,  considerable  albu- 
min, no  sugar,  sp.  gr.  1017.    Urea  12  gm.  to  the  liter. 

Cystoscopic  examination. — A  small  coude  silk  catheter  passes  with  ease 
and  finds  250  cc.  residual  urine.  The  bladder  is  very  irritable,  rebelling 
at  200  cc.  Examination  of  the  prostatic  orifice  shows  an  unusually  irregu- 
lar outline.  The  upper  portions  of  the  lateral  lobes  project  quite  far  into 
the  bladder,  terminating  in  sharp  points.  The  median  lobe  is  small  and 
separated  from  lateral  lobes  by  deep  sulci.  The  mucous  membrane  cover- 
ing the  prostate  is  smooth,  and  there  is  nothing  to  suggest  malignancy. 
The  bladder  wall  is  considerably  trabeculated,  the  ureteral  ridges  are 
prominent  and  their  orifices  negative.  A  careful  search  failed  to  reveal 
any  calculus.  With  the  finger  in  the  rectum  and  cystoscope  in  the  urethra 
the  amount  of  tissue  between  the  two  is  slight. 

Preliminary  treatment. — Catheterization  twice  daily,  irrigation.  Urotro- 
pin  by  mouth.  Under  this  treatment  the  patient  has  been  much  more  com- 
fortable. 

Operation,  April  25,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  were  of  moderate  size  were  enucleated 
with  ease,  and  the  median  lobe  which  was  small  was  extracted  through 
one  of  the  lateral  cavities.  The  ejaculatory  ducts  were  preserved.  The 
wound  was  closed  as  usual  with  double  tube  drainage  for  the  bladder,  and 
light  gauze  packing  for  the  lateral  cavities.  The  patient  stood  the  opera- 
tion well.  Infusion  and  intravesical  irrigation.  Pulse  at  end  of  opera- 
tion 85. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
on  the  day  following  the  operation,  100.4°.  It  remained  normal  after  the 
third  day.  Continuous  irrigation  was  kept  up  for  12  hours  when  the  gauze 
packing  was  removed.  The  tubes  were  removed  on  the  second  day.  The 
patient  was  up  in  a  chair  on  the  third  day.  Interval  urination  was  estab- 
lished immediately  after  removal  of  the  tubes,  urine  coming  through  the 
penis  on  the  fourth  day  and  the  perineal  fistula  closing  on  the  14th  day. 
The  patient  walked  about  considerably  after  the  first  week,  and  was  dis- 
charged on  the  25th  day,  when  the  following  note  was  made:  The  wound 
is  closed,  the  patient  voids  urine  every  four  hours,  in  a  good  stream,  has 
no  pain  nor  dribbling.     He  has  already  had  several  imperfect  erections. 


334  Hugh  H.  Young. 

His  condition  is  excellent.  A  silver  catheter  passes  with  ease,  no  stricture, 
no  residual  urine. 

November  30,  1905. — Letter.  I  can  void  urine  naturally,  have  had  no  in- 
strumentation, urinate  five  or  six  times  during  the  day  and  three  or  four 
during  the  night.  The  amount  voided  is  usually  small,  never  as  much  as 
half  a  pint,  but  the  bladder  is  irritable.  Erections  are  present  but  imper- 
fect, and  sexual  intercourse  is  unsatisfactory,  but  was  so  before  the  opera- 
tion. My  general  health  is  excellent.  "^Tien  I  void  urine  the  stream  is 
large  and  free  enough  at  the  beginning,  then  it  becomes  small  and  some- 
times in  driblets. 

January  27,  1906. — .Letter.  I  void  urine  twice  during  the  night  and  six 
times  during  the  day.  I  void  urine  freely  in  a  large  stream  unless  I  try 
to  hold  it  too  long.  When  the  desire  to  urinate  comes  on  I  must  attend  to 
it  at  once,  else  there  may  be  an  escape  of  a  small  amount  of  urine.  I  have 
no  other  incontinence.     I  have  no  pain  or  irritation. 

May  5,  1906. — Letter.  I  void  urine  naturally  and  have  not  used  a  cath- 
eter. If  I  do  not  respond  to  the  call  promptly  there  is  a  slight  escape  of 
urine,  but  I  have  no  definite  incontinence.  I  retire  at  10.30  and  arise  about 
4  o'clock  to  urinate  and  again  at  5.30  when  I  get  up.  The  amount  voided 
is  never  as  much  as  half  a  pint.  I  suffer  no  pain.  I  have  imperfect  erec- 
tions, no  worse  than  before  operation.  My  general  health  is  excellent  and 
I  have  gained  in  weight.  No  one  can  dispute  the  wonderful  success  of  the 
operation  and  the  unspeakable  relief. 

Pathological  report. — The  specimen,  G.  U.  152,  consists  of  the  three  lobes 
of  the  prostate,  each  removed  in  one  piece  and  weighing  in  all  S^o  gm. 
The  lateral  lobes  are  each  about  2  cm.  in  diameter.  Their  surfaces  are 
irregular,  and  on  section  considerable  stroma  and  very  little  gland  tissue 
is  evident.  No  dilated  glands  are  seen.  The  median  lobe  is  very  small, 
measuring  1.5xlx  .8  cm.  and  presents  the  same  characteristics  as  the  lat- 
eral lobes. 

Microscopic  examination. — The  hypertrophy  is  only  a  moderately  gland- 
ular one,  there  being  present  a  large  amount  of  stroma.  Within  the  mod- 
erately glandular  lobules  the  acini  seem  rather  compressed  and  elongated. 
The  epithelium  lining  the  acini  presents  a  great  deal  of  degeneration, 
while  the  stroma  seems  to  be  undergoing  a  marked  fibrous  hyperplasia. 
The  arteries  show  quite  a  marked  thickening. 

Case  85. — Slight  median  and  lateral  hypertrophy.  Vesical  calculus.  Cure. 
Followed  13  months. 

No.  929.     A.  S.,  age  64,  married,  admitted  April  7,  1905. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  with  a  sudden  attack  of  intense  pain  along  the 
urethra  four  and  one-half  years  ago.  About  the  same  time  both  testicles 
became  swollen  and  painful.  Since  then  patient  has  been  troubled  with 
frequent  micturition  with  pain  during  and  occasionally  at  the  end  of 
urination,  and  of  late  slight  hematuria.    Has  recently  passed  several  small 


study  of  14^5  Cases  of  Perineal  Prostatectomy.  335 

calculi.  There  has  never  been  complete  retention  of  urine,  but  he  has 
catheterized  himself  occasionally  on  advice  of  his  physician. 

8.  P. — Urination  every  hour  night  and  day  with  considerable  difficulty, 
pain  in  urethra  and  occasionally  slight  hemorrhage. 

Sexual  powers. — There  has  been  a  marked  decrease  in  his  sexual  power, 
but  erections  still  occur  occasionally.  His  general  health  has  remained 
good. 

Examination. — Fairly  well  nourished  man  with  lips  of  good  color.  Chest, 
abdomen,  negative. 

Genitalia. — The  left  epididymis  is  indurated. 

Rectal. — The  left  lobe  of  the  prostate  is  about  normal  in  size,  smooth, 
fairly  soft  except  at  the  upper  end  where  it  is  slightly  indurated  and 
adherent  to  the  seminal  vesicle.  The  right  lobe  is  about  twice  as  large 
as  the  left,  is  prominent,  indurated  but  compressible  and  not  of  stony 
hardness.  Its  contour  is  slightly  irregular,  and  at  its  upper  end  is  an 
oblong,  smooth  oval  mass  markedly  indurated,  projecting  into  the  region 
of  the  right  seminal  vesicle  for  a  distance  of  about  1.5  cm.  The  seminal 
vesicle  above  is  not  indurated,  and  there  is  no  mass  extending  outward 
toward  the  pelvis,  no  periprostatic  induration,  no  intravesicular  mass,  no 
enlarged  glands.    The  rectal  mucosa  is  soft  and  not  adherent. 

Cystoscopic. — A  small  coude  catheter  passes  with  ease  and  finds  50  cc. 
residual  urine.  The  bladder  is  small  and  irritable.  The  lateral  lobes  are 
apparently  not  at  all  intravesically  enlarged  and  there  are  no  clefts  be- 
tween them  in  front.  There  is  a  small  but  definite  median  enlargement 
in  the  shape  of  a  rounded  bar,  but  there  are  no  clefts  on  either  side.  The 
mucous  membrane  is  smooth.  A  fairly  large  roughly  granular,  white 
calculus,  freely  movable  in  the  bladder  is  seen.  The  bladder  is  moderately 
trabeculated,  chronically  inflamed.     There  are  no  diverticula  present. 

Urinalysis. — Cloudy,  alkaline,  no  sugar,  albumin  in  small  amounts. 
Microscopically  pus  and  epithelial  cells,  cocci,  and  bacilli.  Urea  G-12  to 
liter.     Total  urine  1600  cc. 

The  patient  developed  pleurisy  soon  after  admission  and  operation  was 
delayed  on  that  account. 

Operation,  April  25,  1905. — Ether.  Perineal  nrostatectomy  by  the  usual 
technique.  Extraction  of  a  moderately  large  calculus  through  the  wound. 
The  lateral  lobes  were  only  slightly  enlarged  and  were  quite  adherent, 
but  each  was  removed  in  one  piece.  A  small  median  lobe  about  2  cm. 
in  diameter  was  removed  through  one  of  the  lateral  cavities  without 
tearing  away  any  of  the  mucous  membrane.  The  urethra  was  then 
incised  along  lateral  wall  to  the  neck  of  the  bladder,  and  the  calculus 
removed.  The  wound  was  closed  as  usual  with  double  tube  drainage  and 
lateral  gauze  packs.    The  levators  were  drawn  together  with  catgut. 

The  patient  stood  the  operation  well,  pulse  at  the  end  being  80.  Infusion 
and  continuous  irrigation  on  return  to  room.  The  patient  reacted  well. 
His  temperature  rose  to  101.2°  on  the  day  after  the  operation,  but  fell 
promptly  and  remained  normal  afterwards.  The  irrigation  was  dis- 
continued after  12  hours,  the  tubes  were  removed  within  24  hours  and  the 


336  Hugh  E.  Young. 

gauze  within  48  hours.  He  was  up  in  a  chair  on  the  third  day  and  urine 
passed  through  the  urethra  on  the  fourth  day.  The  perineal  fistula  closed 
finally  on  the  tenth  day,  and  at  that  time  he  was  able  to  retain  urine 
for  five  hours.  He  was  discharged  on  the  15th  day,  voiding  at  intervals 
of  about  three  hours  with  perfect  control,  size  and  force  of  stream  good. 
A  silver  catheter  passed  with  ease  and  found  no  residual  urine.  There 
were  no  complications. 

Xoveynber  30.  1905. — Letter.  The  wound  has  remained  closed.  I  void 
urine  two  or  three  times  during  the  night  and  six  to  nine  times  during 
the  day.  I  suffer  a  slight  pain  at  the  end  of  urination,  and  if  I  procrastin- 
ate too  long  between  urinations  I  have  pain  in  the  bladder.  The  urinary 
stream  is  full  and  free,  but  I  do  not  void  more  than  three  and  one-half 
ounces  at  a  time.  I  have  erections,  but  imperfect.  My  general  health  is 
good  and  I  have  gained  20  pounds.  The  urine  is  straw  color  and  there 
is  no  sediment. 

Alay  15,  1906. — Letter.  I  void  urine  naturally,  but  not  without  some 
pain,  about  every  two  and  one-half  hours  during  the  day  and  once 
at  night.  I  sometimes  pass  a  little  over  a  half  a  pint  at  a  time.  I  suffer 
no  pain  at  the  end  of  urination.  I  have  erections  and  have  had  intercourse, 
but  it  is  not  very  satisfactory.  My  general  health  is  good,  I  have  gained 
in  weight,  I  am  markedly  improved  but  cannot  say  that  I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  151,  consists  of  the  three  lobes 
of  the  prostate  each  removed  in  one  piece.  The  weight  is  about  G-13. 
The  median  lobe  measures  1.6  x  1.5  x  1  cm.  in  size.  The  right  lobe  meas- 
ures 3  X  1.5  X  1  cm.  The  left  measures  2  x  1.3  x  2  cm.  The  character  of 
the  three  lobes  is  somewhat  similar,  the  surface  is  irregular,  and  the 
cut  surface  is  fairly  homogeneous  with  few  acini  showing. 

Microscopic  examination  shows  a  moderately  glandular  hypertrophy. 
Lobulated  areas  rich  in  gland  tissue,  alternating  with  areas  in  which  the 
acini  are  rather  sparsely  distributed,  and  in  which  the  stroma  pre- 
dominates. In  some  areas  marked  glandular  proliferation  is  going  on 
while  in  others  hyperplasia  of  the  stroma  with  atrophy  of  the  parenchyma 
is  taking  place.  The  stroma  contains  rather  more  fibrous  tissue  than 
muscle.    Some  areas  of  chronic  inflammatory  infiltration. 

Case  86. — Moderate  hypertrophy  of  median  and  lateral  loies.  Cathet- 
erism.     Cured.     Xo  complications. 

No.  910.    T.  B.,  age  61,  married,  admitted  April  25,  1905. 

Complaint. — "  Difficulty  of  urination.     Intermittent  catheterism." 

The  patient  had  gonorrhoea  at  the  age  of  16,  and  several  times  later. 
Since  1864,  has  had  no  urethral  discharge,  no  evidence  of  stricture,  and 
sexual  powers  have  been  normal.  Present  illness  began  six  years  ago  with 
slight  difficulty  and  frequency  of  urination.  After  that  patient's  symptoms 
gradually  increased  and  two  years  ago  had  retention  of  urine  for  the  first 
time.  During  the  past  18  months  the  patient  has  used  the  catheter  at 
least  once  a  day,  and  of  late  three  times  a  day. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  337 

/S.  P. — Urination  is  difficult,  considerable  straining  being  required.  He 
uses  a  catheter  three  times  at  night,  but  none  in  the  day.  The  only 
pain  he  has  is  slight  and  dull  in  character  and  located  in  the  lumbar 
region.     His  sexual  powers  are  satisfactory. 

Examination. — Patient  is  a  sturdy  looking  man  with  mucous  membranes 
of  good  color  and  slight  arteriosclerosis.     Chest  and  abdomen,  notes  lost. 

Both  testicles  are  very  small,  but  the  genitalia  are  otherwise  normal. 
The  prostate  is  moderately  hypertrophied,  smooth,  rounded,  elastic  but 
fairly  firm.  Slight  induration  at  the  base  of  the  left  seminal  vesicle,  but 
the  right  is  normal.  The  prostatic  secretion  is  composed  almost  entirely 
of  pus  cells,  a  few  lecithins  and  large  granule  cells  are  present.  The  urine 
is  acid,  slightly  cloudy  and  contains  pus  and  bacilli  in  great  number.  A 
silver  catheter  passes  with  ease.  300  cc.  residual  urine  present.  The 
bladder  capacity  is  slightly  contracted.  The  cystoscope  shows  a  fairly 
large  median  lobe  bilobular  in  shape.  The  lateral  lobes  do  not  project 
into  the  bladder.  Considerable  trabeculation  of  the  vesical  wall  and  a 
moderate  cystitis  is  present.  The  left  ureter  is  secreting  normal  urine. 
The  right  ureter  cannot  be  seen  as  it  lies  behind  the  median  lobe  of  the 
prostate. 

Preliminary  treatment. — Regular  catheterization,  intravesical  irrigations 
and  urotropin  for  three  days. 

Operation,  April  28,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  moderately  enlarged,  but  quite 
adherent  and  were  removed  with  difficulty.  The  median  lobe  was  removed 
through  the  right  lateral  cavity,  a  small  tear  being  made  in  the  lateral 
wall  of  the  urethra,  but  no  mucous  membrane  being  removed.  The  rest 
of  the  urethra  and  ejaculatory  ducts  were  preserved  intact.  A  finger  intro- 
duced through  the  urethra  into  the  bladder  showed  no  enlargement  remain- 
ing. There  was  very  little  hemorrhage  and  the  patient  stood  the  operation 
well.  The  wound  was  closed  as  usual  with  double  tube  drainage  for  the 
bladder  and  continuous  irrigation  was  supplied  on  the  table  and  after  his 
return  to  the  ward,  when  a  submammary  infusion  of  salt  solution  was 
also  given.     Pulse  at  end  of  operation  80. 

May  24,  1905. —  (26th  day.)  The  patient  has  had  an  uninterrupted 
convalescence.  The  gauze  was  removed  on  the  day  after  the  operation 
and  the  tubes  on  the  second  day.  After  that  there  was  constant  leakage 
through  the  perineum  for  two  days,  but  after  that  interval  urination 
every  two  hours  was  established.  The  patient  was  out  of  bed  on  the 
third  day.  On  the  fourth  day  the  urine  began  to  pass  through  the  penis, 
and  the  fistula  finally  closed  on  the  21st  day.  No  epididymitis.  The  patient 
now  does  not  arise  at  night  to  urinate  (a  period  of  eight  hours).  There 
is  no  urgency,  no  incontinence,  no  dribbling  except  a  few  drops  at  end 
of  urination.  He  can  hold  his  urine  for  five  hours  during  the  day,  has 
no  pain  and  "  enjoys  urinating."  The  wound  was  closed,  there  is  no 
fistula,  a  catheter  meets  no  obstruction  and  there  is  no  residual  urme 
present.  He  has  had  no  instrumentation  since  operation.  The  urine  is 
almost-  clear   and   contains   only   a  few   bacilli.     Patient   was   discharged 


338  Hugh  H.  Young. 

from  the  hospital  on  the  27th  day.  The  highest  temperature  was  100.5° 
on  the  day  after  the  operation,  after  that  normal. 

November  30,  1905. — Letter.  I  void  urine  naturally  three  times  during 
the  day  and  once  or  twice  at  night  from  one-half  to  three-quarters  of  a  pint 
at  a  time.  The  wound  has  remained  healed  and  I  suffer  only  a  very  slight 
pain  occasionally.  I  have  only  partial  erections  and  intercourse  is  not 
satisfactory,  the  ejaculation  being  small  in  amount.  My  general  health  is 
excellent  and  I  consider  myself  cured. 

May  8,  1906. — Letter.  I  void  urine  naturally,  four  or  five  times  during 
the  day  and  once  or  twice  at  night,  about  a  pint  at  a  time.  I  suffer  no 
pain.  Sexual  intercourse  is  not  satisfactory,  erections  being  too  weak  and 
the  ejaculation  very  slight.  My  general  health  is  good,  I  have  gained 
in  weight  and  consider  myself  entirely  well. 

Case  87. — Slight  hypertrophy.  Great  frequency.  Retention  two  weeks. 
Pain.    Cure.    Followed  19  months. 

No.  909.    J.  D.  B.,  age  55,  married,  admitted  April  21,  1905. 

Complaint. — "  Difficulty  and  frequency  of  urination  and  pain." 

The  patient  had  gonorrhoea  25  years  ago,  a  severe  attack,  but  not 
followed  by  gleet  nor  stricture.  Urethritis  a  second  time  seven  years  ago, 
severe  and  followed  by  difficulty  of  urination. 

The  present  illness  began  with  frequency  and  difficulty  of  urination 
during  the  attack  of  gonorrhoea  seven  years  ago.  Since  then  there  has 
been  a  gradual  increase  in  these  symptoms,  but  at  times  they  are  worse 
than  at  others.  Intermittent  attacks  of  irritation  with  marked  frequency 
of  urination,  often  10  to  12  times  every  night  have  occurred.  At  other 
times  he  can  retain  urine  for  three  or  four  hours.  Complete  retention 
of  urine  came  on  for  the  first  time  in  January,  1905,  and  the  catheter 
was  necessary  for  two  weeks.  Since  then  he  has  used  the  catheter  once  a 
day.  For  one  year  patient  has  had  pain  in  the  left  lumbar  region,  inter- 
mittent, dull  and  lasting  only  for  a  short  time.  Occasionally  this  pain 
would  radiate  to  the  left  groin  and  testicle,  but  it  was  never  of  a  severe 
colicky  character. 

jSf.  P. — The  patient  voids  urine  about  12  times  during  the  night,  and 
every  15  to  30  minutes  during  the  day.  When  the  desire  to  urinate  comes 
on  there  is  a  pain  in  the  neck  of  the  bladder  and  an  urgency  of  urination. 
There  is  no  pain  in  the  urethra  nor  any  hematuria.  No  pain  in  the 
rectum  or  thighs.  The  stream  of  urine  is  small,  difficult  to  start  and 
followed  by  dribbling.  He  has  not  lost  weight.  Erections  are  present; 
coitus  causes  pain. 

Examination. — Patient  is  a  healthy  looking  man.  Chest  and  abdomen 
negative. 

Rectal  examination. — The  lateral  lobes  of  the  prostate  are  moderately 
hypertrophied,  smooth,  soft.  The  seminal  vesicles  are  not  indurated  and 
no  enlarged  glands  are  felt.  The  urine  is  slightly  cloudy,  acid,  and  contains 
numerous  pus  and  epithelial  cells  and  bacilli.  A  catheter  passes  easily 
and  finds  only  60  cc.  residual  urine.  The  bladder  is  contracted,  holding 
only  300  cc. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  339 

The  cystoscopic  examination  is  unsatisfactory  owing  to  hemorrhage. 
The  bladder  wall  was  seen  to  be  considerably  trabeculated.  No  stone  was 
present.  The  median  portion  of  the  prostate  was  slightly  enlarged.  With 
the  finger  in  the  rectum  and  cystoscope  in  the  urethra  the  beak  could  be 
easily  felt,  but  there  is  considerable  increase  in  the  median  portion  of  the 
prostate. 

Operation,  April  29,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  not  greatly  enlarged,  but  adherent 
in  their  deeper  portions.  The  median  lobe  was  so  small  that  it  could  not 
be  engaged  with  the  tractor.  The  finger  was  then  inserted  and  a  median 
lobe  about  1  cm.  in  diameter  drawn  into  the  left  lateral  cavity  and 
enucleated.  The  right  lateral  wall,  floor  of  the  urethra,  and  ejaculatory 
ducts  were  preserved  intact.  A  small  tear  was  made  in  the  left  lateral 
wall  in  removing  the  middle  lobe.  There  was  considerable  hemorrhage 
but  the  patient  stood  the  operation  well.  Double  tube  drainage  and 
closure  as  usual.  Saline  infusion  and  continuous  irrigation  on  return  to 
the  ward. 

Convalescence. — The  patient  reacted  well  from  the  operation.  The  tubes 
were  removed  on  the  second  day  and  the  gauze  on  the  third  day.  The 
urine  began  to  flow  from  the  urethra  on  the  sixth  day  and  the  fistula  healed 
on  the  13th.  Patient  was  up  in  a  wheel  chair  on  the  third  day  and  has 
been  walking  since  the  fourth  day.  Temperature  rose  to  101°,  but  was 
normal  after  the  third  day. 

May  18,  1905. —  (20th  day.)  There  has  been  no  epididymitis  nor  other 
complications.  He  has  perfect  control  and  there  is  no  dribbling.  The 
wound  is  healed.  A  silver  catheter  passes  with  ease,  no  stricture  encount- 
ered and  no  residual  urine.  The  urine  is  almost  clear,  contains  only  a 
few  pus  cells  and  no  bacteria.    The  patient  is  discharged  from  the  hospital. 

Novemder  30,  1905. — Letter.  I  void  urine  naturally  six  or  eight  times 
during  the  day  and  two  to  four  times  at  night,  about  one-half  pint  at  a 
time.  The  perineal  wound  has  remained  closed,  I  suffer  no  pain.  Have 
partial  erections,  but  intercourse  is  not  satisfactory.  My  general  health 
is  excellent  and  I  consider  myself  cured. 

May  28,  1906. — Letter.  I  have  not  had  to  use  a  catheter  and  void  urine 
naturally  about  eight  times  during  the  day  and  two  to  four  times  at 
night  and  as  much  as  half  a  pint  at  a  time.  I  have  no  pain.  Erections 
and  sexual  intercourse  is  improving,  but  is  not  as  yet  entirely  satisfactory. 
I  have  had  no  complications  nor  treatment.  My  general  health  is  very 
good,  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  157,  consists  of  three  lobes 
of  the  prostate  removed  each  in  one  piece,  and  weighs  probably  not  more 
than  G-10.  The  median  lobe  measures  1.5  x  .8  x  .5.  The  right  lobe  meas- 
ures 3  X  1  x  1.5  cm.  and  the  left  2.5  x  2.5  x  1.3  cm.  No  mucous  membrane, 
no  ejaculatory  ducts,  no  calculi. 

Microscopic  examination. — Microscopically  the  gland  tissue  is  distrib- 
uted with  slight  tendency  to  lobulation.  In  areas  the  acini  are 
fairly     numerous     while     in     other     areas     the     stroma     predominates. 


340  Hugh  H.  Young. 

In  the  glandular  areas  the  acini  are  small  with  a  rather  dense 
fibro-muscular  frame  work,  and  considerable  endoglandular  pro- 
liferation. The  acini  are  rather  closely  set  together  and  display  but 
very  little  of  the  complexity  so  evident  in  some  of  the  glandular  hyper- 
trophies. The  stroma  in  these  glandular  areas  is  largely  composed  of 
fibrous  tissue  with  here  and  there  some  periacinous  and  interstitial  in- 
flammatory infiltration.  In  the  portions  containing  more  stroma  than 
gland  tissue  the  alveoli  are  for  the  most  part  plugged  with  masses  of 
proliferating  and  degenerating  epithelial  cells,  and  there  is  considerable 
excess  of  fibrous  tissue  over  muscle  in  the  stroma.  Here  and  there  are 
areas  of  interstitial  infiltration,  and  some  periacinous  connective  tissue 
formation. 

In  this  prostatic  tissue  the  gland  and  stroma  are  present  in  about  equal 
proportions;  the  relative  amount  of  each  varying  in  different  areas,  while 
the  alveoli  are  small  rather  closely  aggregated  and  with  a  rather  dense 
interlacing  stroma.  No  evidence  of  malignancy.  The  entire  picture  is 
simply  one  of  prostatitis. 

Case  88. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Catheter 
life.    Cured.    Followed  13  months. 

No.  911.     G.  F.,  age  72,  widowed,  admitted  April  26,  1905. 

Complaint. — "  Complete  retention  of  urine,  catheterism." 

There  is  no  history  of  gonorrhoea. 

Present  illness  began  about  15  years  ago  with  frequency  and  slight 
difficulty  of  urination.  This  gradually  increased,  but  he  did  not  have  to 
be  catheterized  until  three  years  ago,  but  chronic  retention  of  urine  has 
only  been  present  for  the  past  year  and  he  now  catheterizes  himself  every 
five  hours  and  is  unable  to  void  naturally.  He  suffers  no  pain,  has  not  lost 
weight.  Occasionally  has  erections,  but  no  desire,  and  has  not  had 
intercourse  for  about  10  years. 

Examination. — The  patient  is  a  sturdy  looking  man  for  his  age. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  globular 
in  shape  and  about  the  size  of  an  orange.  The  surface  is  smooth  and 
regular,  with  the  exception  of  the  anterior  portion  of  the  right  lateral 
lobe  where  a  small  lobule  is  felt.  The  consistence  is  firm,  and  there  is 
distinct  induration  at  the  base  of  the  right  seminal  vesicle.  The  prostatic 
secretion  contains  many  pus  cells,  few  granule  cells  and  lecithins.  The 
urine  is  cloudy,  and  no  sugar,  no  albumin.  Microscopically  pus  cells  and 
bacteria,  no  casts.    Urea,  27  gr.  to  the  liter. 

Cystoscopic  examination. — The  patient  is  unable  to  void  urine.  A  coude 
catheter  enters  with  ease  and  finds  a  bladder  capacity  of  350  cc.  The 
cystoscope  shows  hypertrophy  of  both  lateral  lobes,  and  a  small  round 
enlargement  of  the  median  lobe.  There  is  a  deep  sulcus  between  the 
lateral  lobes  in  front.  The  bladder  is  trabeculated.  There  is  no  stone 
present.    The  left  ureter  can  be  seen  but  the  right  cannot. 

Operation,  April  29,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.     The   lateral    lobes   were   moderately   enlarged.     The   median 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  3-41 

lobe  measured  2x2x3  cm.  in  size,  and  was  easily  enucleated  through  the 
right  lateral  cavity,  but  in  so  doing  a  tear  was  made  in  the  urethra.  After 
removal  of  the  tractor  a  finger  was  inserted  and  found  that  all  hyper- 
trophied  tissue  had  been  removed.  The  lateral  cavities  were  packed  with 
gauze.  Double  catheter  drainage  was  supplied  and  the  wound  was  closed 
as  usual.  Saline  infusion  and  continuous  irrigation  given  on  return  to 
ward.  There  was  very  little  hemorrhage  and  patient's  condition  at  the 
end  was  good. 

Convalescence. — Gauze  and  catheters  were  removed  48  hours  after  the 
operation  and  the  patient  was  at  once  gotten  out  of  bed.  The  next  day  he 
began  to  walk.    The  fistula  closed  on  the  16th  day. 

May  18,  1905. —  (20th  day.)  The  fistula  is  closed  and  urine  passes  freely 
and  in  a  large  stream  through  the  urethra.  The  patient  can  hold  his 
urine  for  two  hours.  There  is  no  incontinence,  but  a  few  drops  dribble 
away  at  the  end  of  urination.  He  has  had  no  instrumentation  and  no 
complications.  A  silver  catheter  passes  without  obstruction  through  the 
membranous  urethra,  but  it  would  not  pass  into  the  bladder  owing  to 
dilated  pouch-like  condition  of  the  prostatic  urethra  in  which  it  was 
impossible  to  find  the  prostatic  orifice.  The  patient  was  discharged  with 
instructions  to  take  urotropin  and  to  hold  urine  as  long  as  possible  in 
order  to  dilate  bladder. 

Noveviber  30,  1905. — Letter.  I  void  urine  naturally  and  consider  myself 
cured.  The  catheter  has  not  been  used  since  the  operation.  There  is 
no  fistula.  I  void  urine  once  during  the  night  and  about  three  times 
during  the  day,  250  cc.  at  a  time.  I  have  no  pain.  Erections  have  re- 
turned and  coitus  would  be  possible  if  I  were  so  inclined.  I  have  had  no 
complications  and  my  general  health  is  excellent. 

May  20,  1906. — Letter.  I  urinate  naturally,  four  or  five  times  during 
the  day  and  once  at  night  and  about  three-quarters  of  a  pint  at  a  time. 
I  have  no  pain.  Erections  have  returned,  but  I  do  not  attempt  inter- 
course. My  general  health  is  very  good,  and  I  consider  myself  entirely 
cured. 

Pathological  report.  The  specimen,  G.  U.  156,  consists  of  three  pieces 
of  tissue  representing  the  three  lobes.  The  lateral  lobes  are  soft  in 
consistency,  lobulated,  and  weigh  about  10  gr.  The  median  portion  is  a 
small  irregular  mass  distinctly  firmer  than  either  of  the  lateral  lobes.  A 
few  small  spheroids  are  present.  The  ejaculatory  ducts  have  not  been 
removed.    No  calculus  is  present. 

Microscopic  examinati07i. — The  hypertrophy  is  a  moderately  glandular 
one  with  arrangement  in  lobules.  The  acini  are  moderately  dilated  and 
in  some  areas  show  considerable  cystic  degeneration.  There  is  present 
everywhere  quite  a  marked  prostatitis,  and  many  of  the  acini  are  filled 
with  desquamated  epithelial  cells  and  some  leucocytes.  There  is  present 
in  the  stroma  considerable  round  and  polynuclear  infiltration  with  the 
formation  of  some  inflammatory  tissue.  The  stroma  contains  a  moderate 
amount  of  muscle,  although  there  is  more  connective  tissue  than  muscle 
present.     The  arteries  show  in  areas  a  moderate  degree  of  thickening. 


342  Hugh  H.  Young. 

Case  89. — Severe  stricture  of  urethra,  vesical  ulcer,  slight  enlargement 
of  prostate.  Urethrotomy,  prostatectomy,  curettage  of  ulcer.  Death 
eighth  day.    Hemorrhage. 

No.  685.    H.  C.  B.,  age  53,  married,  admitted  August  1,  1904. 

Complaint. — "  Frequent  and  difficult  urination." 

From  his  16tli  to  his  35th  year  patient  had  gonorrhoea  pretty  constantly. 
Since  then  he  has  been  free  from  the  disease.  In  1869,  while  under 
treatment  for  gonorrhoea  he  had  difficulty  in  urination  and  an  examination 
revealed  two  strictures  which  were  treated  by  dilatation.  After  that  the 
patient  received  no  treatment  for  10  years  when  the  stricture  had  again 
closed  down  so  that  a  filiform  was  passed  with  difficulty.  After  that  he 
was  treated  by  dilatation  and  electrolysis.  At  the  end  of  two  years  his 
condition  was  fairly  good,  but  soon  the  trouble  recurred.  In  1883,  a  peri- 
neal urethrotomy  was  performed  and  "  the  bladder  which  was  found  to  be 
encrusted  was  curetted.".  A  little  later  he  began  to  use  a  catheter  and  his 
condition  gradually  became  worse  until  1899,  when  an  internal  urethrotomy 
was  performed,  followed  by  dilatation  to  a  21  American  sound.  The 
treatment  could  not  be  continued,  however,  on  account  of  the  weak  condi- 
tion of  the  patient,  and  micturition  became  so  frequent  that  he  had  to  wear 
a  rubber  urinal  and  suffered  very  greatly  from  pain.  He  has  never 
passed  gravel. 

8.  P. — Urine  dribbles  constantly  into  the  rubber  urinal.  During  the 
night  he  urinates  as  often  as  every  10  minutes.  His  conditon  has  become 
decidedly  worse  during  the  past  year  and  he  has  suffered  great  pain. 

Examination. — The  patient  looks  sick  and  weak.  The  mucous  membrane 
is  pale.  He  is  very  much  concerned  about  himself,  nervous  and  restless. 
The  heart  sounds  are  diminished  in  intensity.  The  lungs  and  abdomen 
are  negative. 

Urethral. — A  number  18  F.  sound  passes  with  difficulty  through  a  very 
firm  stricture  of  the  deep  urethra  beginning  in  the  posterior  portion  of  the 
bulbous  region.  A  small  catheter  is  then  passed  and  50  cc.  residual  urine 
found.    The  bladder  capacity  is  100  cc.  and  this  amount  causes  great  pain. 

Rectal. — The  prostate  is  only  slightly  enlarged.  The  contour  is  normal 
in  shape,  the  consistence  is  slightly  indurated.  The  seminal  vesicles 
are  palpable  and  indurated,  but  only  moderately  so.  The  bladder  above 
feels  very  hard. 

Preliminary  treatment. — Prostatic  massage,  urethral  dilatation,  vesical 
dilatation  by  hydraulic  pressure.  The  stricture  was  very  resistant  and 
after  17  days  treatment  a  filiform  was  necessary.  The  bladder  was  very 
irritable  and  dilatation  difficult.  Prostatic  massage  was  followed  by 
considerable  relief  of  the  pain  and  tenderness  in  this  region  and  his 
condition  improved,  but  urination  was  very  frequent  especially  during  the 
night.    Patient  discharged. 

Second  admission,  April  11,  1905.— The  patient  returns  for  further 
treatment.  He  still  voids  urine  with  difficulty  and  pain  at  very  frequent 
intervals.    A  hard  stricture  of  the  deep  urethra  is  still  present,  but  it  is 


study  of  lJf-5  Cases  of  Perineal  Prostatectomy.  343 

impossible  to  pass  small  sounds  without  flliforms.  The  prostate  is  very- 
little  enlarged,  moderately  indurated,  especially  at  the  upper  end.  The 
seminal  vesicles  are  palpable  and  slightly  indurated  and  the  bladder  very 
hard. 

Urine. — Cloudy,  alkaline,  1026,  no  sugar,  albumin  abundant.  Micro- 
scopically pus,  bacilli,  and  cocci. 

Cystoscopic  examination. — A  small  silver  catheter  passes  with  difficulty 
into  the  bladder,  considerable  force  being  necessary  to  push  it  through 
the  induration  along  the  membranous  and  prostatic  urethra.  100  cc.  residual 
urine  is  found  present.  The  bladder  is  very  irritable  and  it  is  difficult 
to  introduce  100  cc.  of  fluid.  It  is  very  difficult  to  wash  the 
bladder .  clean  of  pus  and  mucous.  The  cystoscope  shows  an 
irregular  prostatic  orifice  covered  by  very  red  granular  redundant  mucous 
membrane.  The  lateral  lobes  are  little  if  at  all  enlarged  and  there  is 
only  a  slight  increase  in  the  median  portion.  The  entire  trigone  and  a 
portion  of  the  adjacent  lateral  walls  of  the  bladder  are  covered  by  a 
thin,  white,  shaggy  exudate  which  cannot  be  dislodged  so  that  it  is 
impossible  to  see  the  conditions  of  the  tissues  beneath  it.  It  appears  to 
cover  the  right  ureteral  orifice,  but  the  left  ureter  opened  just  at  the 
edge  of  the  exudate,  the  posterior  limits  of  which  are  sharply  defined 
and  contrasted  with  fairly  healthy  mucous  membrane  of  the  posterior 
surface  of  the  bladder.  There  was  no  intravesical  tumor  formation.  The 
picture  presented  in  the  trigone  suggests  a  malignant  ulcer,  but  as  it  was 
impossible  to  see  the  base  of  it  no  positive  diagnosis  can  be  made.  With 
finger  in  rectum  and  cj^stoscope  in  urethra  the  beak  can  be  felt,  but  there 
is  an  increase  in  the  thickness  of  the  base  of  the  bladder.  The  median 
portion  of  the  prostate  is  also  slightly  thicker  than  normal.  The  cystoscope 
is  tightly  grasped  by  the  urethra  and  prostate,  so  that  it  is  difficult  to 
manipulate. 

Treatment. — Another  attempt  was  made  to  relieve  patient  by  urethral 
dilatation,  prostatic  massage  and  hydraulic  vesical  dilatation,  but  with 
practically  no  success.  The  patient's  condition  was  very  weak,  he  suffered 
a  great  deal  of  pain  in  the  bladder  and  urethra,  was  constantly  depressed 
and  slept  very  little.  Micturition  was  extremely  frequent  and  difficult. 
Perineal  prostatectomy  was  advised  and  reluctantly  accepted  by  the  pa- 
tient, who  said  that  he  felt  convinced  that  he  was  going  to  die. 

Operation,  May  3,  190-5. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Extensive  perineal  urethrotomy  for  stricture  of  urethra,  vigor- 
ous curettage  of  vesical  ulcer.  The  prostate  itself  was  compartively  small, 
very  fibrous,  but  adherent  to  its  surrounding  capsule.  The  bulb  of  the 
urethra  was  very  fibrous  and  the  membranous  urethra  behind  it  surrounded 
by  much  irregular  fibrous  tissue.  The  membranous  urethra  was  then 
opened  upon  a  grooved  sound  and  examination  showed  that  the  prostatic 
urethra  was  dilated  and  contained  several  valve-like  folds  and  false  pass- 
ages, two  of  which  were  large  enough  to  admit  a  good  sized  sound  and 
apparently  entered  the  substance  of  the  prostate.  The  lateral  lobes,  which 
were  verv  small  and  fibrous  were  excised  with  scissors,  and  the  median 


34:4:  Hugh  H.  Young. 

portion  was  removed  in  ttie  same  way.  Considerable  amount  of  the  dilated 
prostatic  urethra  was  excised.  The  bladder  was  then  thoroughly  curetted 
in  the  region  in  which  the  ulcer  had  been  seen.  Attention  was  then  turned 
to  the  strictured  urethra,  the  walls  of  which  wer-e  found  to  be  greatly 
increased  and  very  fibrous,  and  on  account  of  induration  of  the  anterior 
portion  of  the  bulbous  urethra  internal  urethrotomy  was  performed 
from  the  wound  with  a  blunt  pointed  bistoury.  One  catheter  was  placed 
in  the  urethra  and  the  other  placed  in  the  perineal  wound  in  the  bladder. 
The  lateral  cavities  and  the  urethrotomy  wound  were  packed  with  gauze 
and  the  skin  wound  partially  closed  with  catgut.  Patient  stood  the  oper- 
ation well,  pulse  at  the  end  being  110.  Infusion  and  continuous  irrigation 
after  return  to  ward. 

Convalescence. — The  highest  temperature  was  on  the  day  after  the 
operation  100.6°.  The  pulse  was  never  good,  reaching  120  during  the  first 
three  days  after  the  operation  and  140  on  the  fourth  day.  The  continuous 
irrigation  was  discontinued  after  12  hours,  the  gauze  was  removed  at  the 
end  of  30  hours  and  was  followed  by  a  slight  hemorrhage  which  led  to 
repacking  of  the  wound.     The  catheter  in  the  penile  urethra  drained  well. 

May  7,  1905. — The  patient  has  been  weak,  nauseated  and  vomited  several 
times.  To-day  his  temperature  dropped  and  could  not  be  registered. 
There  was  an  immense  blood  clot  in  the  perineal  wound  which  was 
dislodged  by  the  patient's  straining  to  urinate,  and  this  was  followed  by 
considerable  bleeding.  The  urethra,  bladder,  and  wound  were  irrigated 
and  packed.     The  pulse  is  irregular,  140  to  the  minute. 

May  S,  1905. — Pulse  120,  temperature  100°,  patient  much  more  comfort- 
able. The  dressings  are  soaked  with  urine  and  only  slightly  tinged  with 
blood.  Some  urine  passes  through  the  penis.  The  patient  is  very  nervous 
and  concerned  about  himself.  P.  M.  There  has  been  considerable  bleeding 
in  the  perineal  wound  this  afternoon. 

May  9,  1905. — The  pulse  is  120,  the  temperature  normal.  There  has  been 
less  bleeding  but  the  patient  has  had  two  or  three  attacks  of  intense  pain 
in  the  bladder  followed  by  passage  of  clots  through  penis  and  perineal 
wound. 

May  11,  1905. — Yesterday  the  patient  was  generally  weaker,  felt  cold, 
was  nervous  and  restless.  Temperature  96.  The  dressings  were  soaked 
with  urine  which  was  tinged  with  blood.  Strichnine  was  administered. 
During  the  afternoon  he  had  two  rather  profuse  hemorrhages  from  the 
perineal  wound,  and  he  was  infused.  Packing  the  perineal  wound  did 
not  control  the  hemorrhage.  At  midnight  the  patient  was  catheterized,  and 
suprapubic  cystotomy  performed.  A  large  blood  clot  was  found  in  the 
bladder  which  was  packed  with  gauze.  A  clot  of  blood  was  evacuated 
from  the  perineal  wound  which  was  also  firmly  packed.  The  patient  was 
transfused  on  the  table  and  seemed  to  stand  the  operation  well,  but 
shortly  afterward  his  pulse  became  weak  and  irregular  and  his  respiration 
shallow.  At  7  a.  m.  to-day  he  was  restless  and  in  a  stupor  and  the  pads 
were  soaked  with  urine.  There  has  been  no  fresh  hemorrhage.  His  hands 
and  feet  were  cold  and  cynosed.     Pulse  was  irregular,  weak,  116.     After 


study  of  H5  Cases  of  Perineal  Prostatectomy.  345 

that  the  pulse  and  respiration  gradually  grew  worse,  did  not  respond  to 
stimulants  or  infusions  and  the  patient  died  at  eleven  o'clock.  A  vigorous 
attempt  was  made  to  get  an  autopsy,  but  without  success. 

Pathological  report. — The  specimen,  G.  U.  154,  consists  of  the  three 
lobes  of  the  prostate  removed  in  one  piece  and  weighs  G-7.  The  right  lobe 
weighs  G-3.5,  measures  2.5  x  2  x  1.5  cm.,  is  fairly  smooth,  oval,  and  on 
section  shows  considerable  stroma  and  a  small  amount  of  gland  tissue. 
The  left  lobe  weighs  G-3,  and  measures  2.5x2x1.5  cm.;  it  is  very  irregular 
and  considerably  torn  and  on  section  is  similar  to  right.  The  median 
lobe  is  a  small  mass,  weighing  G-.5  and  measuring  1.5  x  1.3  x  .5  cm.  No 
mucus  membrane,  no  ducts,  no  calculi.  The  scrapings  from  the  vesical 
ulcer  have  been  lost. 

Microscopic  examination. — Microscopically  the  sections  contain  very 
few  glandular  alveoli.  About  nearly  all  of  the  ducts  there  is 
a  polynuclear  and  round  cell  infiltration  with  formation  of  new 
connective  tissue  and  within  many  areas  compresion  of  the 
glands.  The  infiltration  is,  for  the  most  part,  periacinous,  and 
within  the  lumina  of  the  ducts  there  is  endoglandular  proliferation 
and  degeneration  of  the  epithelial  cells.  A  few  leucocytes  are  seen  in 
the  culs-de-sac.  The  stroma,  as  was  said  above,  is  greatly  in  excess  of 
the  gland  tissue,  is  quite  dense  and  compact,  and  seems  for  the  most  part 
fibrous  tissue  although  there  is  present  a  fair  amount  of  smooth  muscle. 
It  is  distinctly  a  fibro-muscular  prostate  with  predominance  of  the  fibrous 
tissue,  and  diminution  in  the  gland  elements,  and  the  whole  picture  is  that 
of  prostatitis  rather  than  prostatic  hypertrophy. 

Case  90. — Small  rounded  median  lohes.  Contracted,  Madder.  Occasional 
complete  retention.    Cure. 

No.  916.    E.  P.  E.,  age  50,  married,  admitted  April  29,  1905. 

Complaint. — "  Bladder  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  10  years  ago  with  an  attack  of  burning  in  the 
urethra  and  frequency  of  urination.  During  the  next  three  years  had 
similar  attacks  at  intervals  of  two  to  four  weeks.  About  seven  years 
ago  began  to  have  slight  difficulty  of  urination,  and  one  year  later 
complete  retention  of  urine  requiring  catheterization.  Since  then  has  had 
to  catheterize  himself  on  numerous  occasions,  but  as  a  rule  has  voided 
naturally,  but  very  frequently.    Has  had  no  hematuria  nor  severe  pain. 

S.  P. — The  patient  urinates  every  two  hours  and  from  two  to  four  times 
at  night.  Occasionally  he  is  unable  to  void  and  has  to  pass  a  catheter, 
usually  finding  about  five  ounces  of  urine.  Occasionally  there  is  a  slight 
pain  in  the  urethra  extending  to  the  end  of  the  penis,  and  a  spasm  in  the 
bladder  at  the  end  of  urination.  He  has  never  passed  a  calculus  and  has 
had  no  pain  in  rectum,  perineum,  or  thighs. 

Sexual  powers. — Present. 

Examination. — The    patient    is    a    well    nourished    man    with    lips    and 
mucous  membranes  of  good  color.     Chest  and  abdomen  are  negative. 
Vol.  XIV.— 23, 


346  Hugli  H.  Young. 

Rectal. — The  prostate  is  only  slightly  hypertrophied.  The  right  lobe 
being  a  little  larger  and  more  prominent  than  the  left.  It  is  soft  and 
smooth.    The  seminal  vesicles  are  negative. 

Gystoscopic. — A  catheter  enters  with  ease  and  finds  only  15  cc.  residual 
urine.  The  bladder  capacity  on  forced  distention  is  only  225  cc,  the 
patient  complaining  of  pain  before  that  amount  is  injected.  The  cystoscope 
shows  a  small  rounded  median  lobe  with  a  deep  sulcus  on  each  side. 
The  lateral  lobes  are  not  enlarged  and  there  are  no  clefts  between  them 
in  front.  The  bladder  is  very  little  trabeculated,  there  is  no  inflammation 
and  the  ureters  appear  normal.  With  finger  in  rectum  and  cystoscope  in 
urethra  very  little  enlargement  is  to  be  felt  (the  cystoscope  evidently  in 
one  of  the  clefts). 

Note. — The  absence  of  residual  urine,  cystitis  and  vesical  trabeculation 
would  seem  at  first  sight  to  show  that  an  operation  was  unnecessary.  The 
frequency  and  difl&cult  of  urination  and  occasional  attacks  of  retention 
of  urine,  however,  made  patient  demand  an  operation. 

Urinalysis. — Cloudy,  1014,  acid,  no  sugar,  a  trace  of  albumin,  micro- 
scopically pus  cells  and  bacilli.    Urea,  G-16  to  liter. 

Operation,  May  3,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  easily  enucleated,  the  left  being  small, 
the  right  moderately  hypertrophied.  The  median  lobe  was  drawn  into 
the  right  lateral  cavity  by  means  of  the  tractor  and  easily  enucleated. 
The  urethra  and  ejaculatory  ducts  were  preserved.  The  wound  was  closed 
as  usual  with  double  drainage  tubes  and  light  packs  for  the  lateral 
cavites.  The  patient  stood  the  operation  well,  the  pulse  at  the  end  being 
100.    No  infusion,  no  irrigation. 

Convalescence. — The  highest  rise  of  temperature  was  on  the  evening 
after  the  operation  99.7°,  after  that  the  patient's  temperature  was  practic- 
ally normal.  There  was  considerable  blood  in  the  urine  for  the  first  30 
hours,  and  when  the  gauze  was  removed  at  the  end  of  24  hours  there 
was  considerable  hemorrhage  so  that  the  wound  was  repacked.  During 
the  next  four  days,  the  patient  complained  of  severe  pain  in  the  urethra 
which  was  relieved  by  urethral  irrigation.  On  the  fourth  day  urine  came 
through  the  penis,  the  tubes  having  been  removed  on  the  second  day.  On 
the  sixth  day  the  patient  was  able  to  retain  urine  for  three  or  four 
hours.  The  perineal  fistula  closed  on  the  15th  day.  Three  weeks  after 
the  operation  there  was  very  slight  pain  and  tenderness  in  the  left 
epididymis  which  subsided  in  24  hours  after  application  of  ice.  On 
discharge  from  hospital  on  the  28th  day  the  patient  was  able  to  hold 
urine  for  five  hours,  stream  was  large,  there  was  no  incontinence,  the 
wound  was  closed,  a  silver  catheter  showed  no  obstruction  and  found 
no  residual  urine. 

November  SO,  1905. — Letter.  I  void  urine  naturally  four  or  five  times 
during  the  day,  usually  not  at  all  during  the  night,  often  one-half  pint 
at  a  time.  The  wound  is  healed  and  I  consider  myself  cured.  Erections 
are  satisfactory,  and  intercourse  normal.     My  general  health  is  good. 

May  9,  1906. — Letter.     I  void  urine  naturally  every  four  or  five  hours 


study  of  llf5  Cases  of  Perineal  Prostatectomy.  347 

during  the  day  and  none  at  night,  about  half  a  pint  or  more  at  a  time. 
I  have  no  pain.  Erections  and  intercourse  are  satisfactory.  My  general 
health  is  good,  and  I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  153,  consists  of  the  three  lobes 
of  the  prostate  and  weighs  G-7.5.  The  right  lobe  2.5  x  2  x  1.2  cm.  weighs 
G-3.5.  The  left  2.5x2x1  cm.  weighs  G-3.5.  The  median  lxlx.6  cm. 
in  size,  weighs  G-.5.  The  surface  of  the  lobes  is  irregular,  in  places  torn, 
the  consistence  is  firm  and  the  section  shows  very  little  spheroid  formation 
and  few  dilated  ducts.    The  consistence  is  homogeneous. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one.  The  acini  are  only  slightly  dilated  although  occasionally  one  sees 
acini  of  considerable  size  with  numerous  intraacinous  off-shoots.  The  acini 
contain  numerous  corpora  amylacea  and  are  lined  by  epithelium  which  is 
usually  two  layers  in  thickness.  The  stroma  is  rather  dense,  and  contains 
an  unusually  large  amount  of  muscle  which  is  irregularly  intermixed  with 
the  connective  tissue.  The  arteries  show  practically  no  thickening.  No 
prostatitis  was  noted  in  the  sections. 

Case  91. — Moderate  enlargement  of  median  and  lateral  lobes.  Catheter 
life.    Attack  of  hemiplegia  previously.     Cure.    Followed  12  months. 

No.  934.     C.  E  R,  age  66,  married,  admitted  May  13,  1905. 

Complaint — >"  Enlarged  prostate." 

Had  gonorrhoea  when  a  young  man. 

Present  illness  began  about  nine  years  ago  with  a  slight  frequency  of 
urination.  He  did  not  have  to  get  up  at  night,  had  no  straining,  and  at  in- 
tervals was  entirely  comfortable.  These  periods  of  increased  frequency 
gradually  grew  worse  until  four  years  ago  he  began  to  have  pain  and  one 
day  a  severe  hemorrhage  into  the  bladder  followed  by  complete  retention 
of  urine.  After  that  slight  hemorrhage  occurred  at  intervals,  but  he  did 
not  have  to  use  a  catheter  until  18  months  ago,  since  which  time  he  has 
used  it  every  day,  at  first  only  at  bed  time.  In  February,  1903,  hemi- 
phlegia  of  the  left  side  came  on,  but  he  subsequently  made  a  complete  re- 
covery. During  the  past  two  months  the  patient  has  had  to  use  the  cath- 
eter from  three  to  five  times  a  day.  Last  month,  while  in  Italy,  catheter- 
ization became  much  more  diificult  and  painful,  and  he  went  at  once  to 
London  to  see  a  surgeon,  who  advised  an  immediate  suprapubic  prostatec- 
tomy. His  son  who  is  a  physician  cabled  him  to  wait  and  went  over  and 
brought  him  to  Baltimore. 

S.  P. — Patient  catheterized  himself  every  four  hours,  and  on  account  of 
a  dull  pain  takes  one-fourth  to  one-half  of  a  grain  of  morphia  daily.  Re- 
tention of  urine  is  practically  complete. 

Sexual  powers. — Are  still  satisfactory. 

Examination. — *Patient  is  a  weak  looking  man  of  sallow  complexion,  but 
lips  are  of  good  color.  The  pulse  is  regular  and  of  good  volume.  Very 
little  arteriosclerosis  is  present.     Chest  and  abdomen  are  negative. 

Rectal  examination. — ^Prostate  Is  moderately  enlarged,  bulges  slightly 
towards  the  rectum,  contour  is  rounded,  surface  smooth,  consistence  is 


348  Hugh  H.  Young. 

elastic,  with  a  little  induration  at  the  upper  end  of  the  right  lobe  which 
does  not  extend  into  the  region  of  the  seminal  vesicles,  both  of  which  are 
soft.  No  indurated  lymphatics  or  glands  are  to  be  felt,  and  the  prostate 
is  not  tender.  Prostatic  secretion  is  composed  largely  of  pus  cells.  Some 
large  granule  cells  are  present,  but  no  spermatozoa. 

Cysioscopic  examination. — A  catheter  passed  with  ease.  Complete  reten- 
tion of  urine  is  present.  The  vesical  capacity  is  large.  The  cystoscope 
shows  a  fairly  large  median  lobe  with  a  deep  sulcus  to  the  left  of  it.  The 
lateral  lobes  are  only  slightly  hypertrophied  intravesically.  The  bladder 
is  markedly  trabeculated  with  numerous  pouches  and  one  diverticula.  In 
the  trigone  in  front  of  the  interureteral  bar  is  a  succession  of  bullse  cov- 
ered with  smooth  mucous  membrane  and  in  places  almost  papillary  in 
character.  At  first  sight  they  suggest  neoplastic  growth,  but  on  further 
study  they  are  shown  to  be  similar  in  appearance  to  the  picture  obtained 
in  bullous  cystitis.  With  finger  in  rectum  and  cystoscope  in  urethra  the 
beak  can  be  felt,  showing  no  induration  in  the  region  of  the  trigone,  and 
a  considerable  increase  in  the  median  portion  of  the  prostate. 

Urinalysis. — Total  quantity  in  24  hours  1100  cc.  Urea  15  gm.  to  liter. 
Urine  acid,  sp.  gr.  1016,  no  sugar,  albumin  in  slight  amount,  pus  cells 
and  bacilli. 

Preliminary  treatment. — Patient  was  catheterized  regularly,  given  water 
in  great  abundance  and  urotropin  for  four  days.  The  blood  pressure  was 
taken  on  the  day  before  the  operation  and  registered  165.  Owing  to  the 
fact  that  he  had  had  one  apoplectic  stroke  he  was  put  upon  sodium  nitrite 
to  reduce  the  blood  pressure. 

Operation,  May  17,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  moderately  enlarged  and  easily  enu- 
cleated. The  middle  lobe  was  removed  partly  with  the  left  lateral  and 
partly  through  the  right  lateral  cavity  after  removal  of  the  left  lateral 
lobe.  The  urethra  was  torn  on  both  sides,  but  the  floor  and  ejaculatory 
ducts  were  preserved  intact.  After  removal  of  the  tractor  a  finger  was 
inserted  into  the  bladder  and  showed  that  the  enlargements  had  been  com- 
pletely removed.  The  blood  pressure  was  taken  before  ether  was  adminis- 
tered and  registered  175.  Under  ether  it  rapidly  rose  to  200,  and  when 
the  patient  was  put  in  the  lithotomy  position  with  the  hips  elevated  and 
the  thighs  flexed  the  blood  pressure  rose  to  220.  In  order  to  reduce  the 
blood  pressure  no  vessels  were  ligated  and  fairly  free  hemorrhage  con- 
tinued, during  the  operation,  but  the  blood  pressure  remained  between 
200  and  225  all  through  the  operation  which  lasted  18  minutes.  As  soon 
as  the  patient  was  removed  from  the  table  the  blood  pressure  fell  to  170. 
The  patient  showed  no  evil  effects  from  the  high  blood  pressure  and  stood 
the  operation  well.  The  woimd  was  closed  as  usual  with  double  rubber 
tube  drainage  for  the  bladder,  light  gauze  packs  for  the  lateral  cavities. 
An  infusion  was  started  before  he  left  the  operating  room,  and  continuous 
irrigation  of  the  bladder  begun  on  his  return  to  the  ward.  During  the  op- 
eration the  pulse  varied  from  80  to  110,  being  90  at  the  end. 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  349 

Convalescence. — The  patient  reacted  well.  For  two  days  the  temperature 
rose  to  100.5°,  but  after  that  remained  practically  normal  for  six  days. 
The  gauze  drains  were  removed  in  30  hours.  On  the  first  and  second  days 
the  drainage  tubes  became  plugged  with  blood  several  times,  causing 
the  bladder  to  fill  up  and  producing  intense  pain.  Boric  irrigations  would 
give  instant  relief  each  time.  The  tubes  were  removed  in  48  hours  and 
patient  was  up  on  the  third  day.  The  urine  began  to  flow  through  the  ure- 
thra on  the  seventh  day,  and  the  perineal  fistula  closed  on  the  14th  day. 
The  right  epididymis  became  inflamed  on  the  ninth  day,  but  subsided  un- 
der ice  caps  in  a  few  days.  On  the  14th  the  patient  was  able  to  hold  his 
urine  as  long  as  five  hours  and  had  no  dribbling.  On  the  18th  day  the 
right  epididymis  became  slightly  swollen  and  tender,  but  subsided  after 
a  few  days.  The  patient  took  nitrites  and  the  blood  pressure  remained 
between  130  and  140.  The  patient  was  kept  fairly  quiet,  not  being  allowed 
to  take  as  much  exercise  as  usual.  He  was  discharged  on  the  27th  day. 
He  was  then  able  to  retain  his  urine  four  or  five  hours,  had  not  been  in- 
strumented and  his  general  health  excellent,  the  wound  completely  closed. 

July  5,  1905. — Letter.  Last  night  I  only  urinated  twice,  my  bladder 
holds  eight  ounces,  my  urine  is  clear,  acid,  and  contains  no  pus. 

Novemher  30,  1005. — Letter.  I  void  urine  naturally,  usually  once  at 
night  and  two  or  three  times  during  the  day,  eight  or  nine  ounces  at  a 
time.  I  suffer  no  pain,  have  had  no  use  for  catheters  and  consider  myself 
cured.     I  have  erections,  and  have  had  intercourse  many  times. 

May  15,  1906. — 'Letter.  I  void  urine  naturally,  250  cc.  at  a  time,  two  or 
three  times  during  the  day  and  usually  once  at  night.  I  have  erections 
and  satisfactory  intercourse.  I  have  had  no  complications  nor  treatment. 
The  wound  has  remained  healed,  and  I  consider  myself  cured. 

Case  92. — Considerable  enlargement  of  median  and  lateral  lobes.  Large 
vesical  calculus.  Contracted  bladder.  Result:  Removal  of  obstruction. 
Frequency  of  urination  due  to  contraction  of  bladder. 

No.  938.     D.  M.  I.,  age  67,  widowed,  admitted  May  18,  1905. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  five  years  ago  with  frequency  of  urination  and 
hesitation  at  the  beginning.  One  year  later  he  began  to  have  pain  during 
urination  and  diagnosis  of  vesical  calculus  was  made,  but  he  did  not  sub- 
mit to  operation.    He  has  never  had  retention  and  does  not  use  a  catheter. 

S.  P. — Micturition  every  15  minutes  during  the  night,  and  about  every 
hour  during  the  day.  Very  little  pain  on  voiding,  but  considerable  pain 
after  micturition,  referred  to  the  middle  of  the  penis,  no  hematuria,  no 
pain  in  hips,  thighs  or  rectum.  Has  not  lost  weight.  Sexual  powers  have 
been  absent  for  several  years.     General  health  good. 

Examination. — The  patient  is  emaciated  and  his  lips  are  pale.  Lungs 
negative. 

Heart. — Soft  systolic  murmur  at  apex,  not  transmitted  to  axilla,  systolic 
murmur  heard  over  the  vessels  in  the  neck. 


350  Hugh  H.  Young. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  forming  a 
mass  about  the  size  of  a  large  lemon.  The  contour  is  rather  irregular, 
especially  on  the  left  side  where  it  is  continuous  with  an  induration  ex- 
tending upward  and  outward  along  the  pelvic  wall.  The  right  lateral  lobe 
is  smooth  and  soft  in  consistence,  and  tender  near  its  apex.  The  left  lat- 
eral lobe  is  also  smooth,  fairly  soft,  but  not  tender.  At  the  upper  end 
running  outward  are  several  hard  cords  adjacent  to  the  induration  de- 
scribed above.  Indurated  cords  are  also  felt,  extending  upward  and  out- 
ward from  the  upper  end  of  the  right  lateral  lobe  and  forming  a  bundle 
about  1%  cm.  in  diameter.  The  notch  at  the  upper  end  of  the  prostate  is 
replaced  by  a  transverse  firm  band  of  tissue,  but  it  is  not  of  stony  hard- 
ness and  has  no  sharp  concave  border  as  in  certain  cases  of  carcinoma. 
No  enlarged  glands  are  to  be  felt  in  the  pelvis. 

Urinalysis. — Slightly  cloudy,  acid,  sp.  gr.  1010,  no  sugar,  albumin  a 
slight  trace,  urea  12  gm.  to  the  liter.  Microscopically,  pus  cells,  bacilli  and 
cocci. 

Gystoscopic  examination. — The  catheter  passes  with  ease  and  finds  about 
100  CO.  residual  urine.  The  bladder  is  very  irritable  and  will  not  admit  100 
cc.  of  irrigating  fluid.  Lavage  caused  hemorrhage  and  cystoscopic  study 
was  unsatisfactory  It  was  possible,  however,  to  make  out  a  large  globu- 
lar median  lobe,  and  a  large,  dark,  irregular  mass  lying  in  front  of  it 
against  the  anterior  wall  of  the  bladder.  Owing  to  hemorrhage  it  was  im- 
possible to  say  whether  it  was  stone  or  neoplasm.  Palpation  of  the  hypo- 
gastric region  shows  that  the  bladder  is  small,  and  markedly  indurated 
and  thickened. 

Operation,  May  22,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  were  fairly  large  were  removed  in 
two  pieces.  The  middle  lobe,  which  measured  3x4x5  cm.  in  size  was 
drawn  down  by  the  tractor  and  enucleated  through  the  right  lateral  cav- 
ity. In  these  manipulations  the  urethra  was  not  torn,  but  the  vesical 
mucous  membrane  covering  the  apex  of  the  middle  lobe  was  removed.  A 
stone  forceps  was  then  inserted  through  this  opening  and  a  calculus  meas- 
uring 2  X  214  X  3  cm.  in  size  was  extracted.  The  wound  was  closed  as  usual 
with  double  catheter  drainage  and  light  gauze  packs  for  the  lateral  cavi- 
ties. There  was  very  little  hemorrhage  and  the  patient  stood  the  operation 
well.  A  submammary  infusion  was  given  on  return  to  the  ward  and  con- 
tinuous irrigation  begun.  The  pulse  at  the  end  of  the  operation  was  100, 
and  half  an  hour  later  72. 

Convalescence. — 'The  patient  reacted  well.  On  the  day  following  the 
operation  the  temperature  rose  to  101.8°,  but  fell  to  normal  the  next  day, 
and  after  four  days  remained  normal.  The  irrigation  was  discontinued 
after  12  hours.  The  gauze  packing  was  removed  without  causing  hemor- 
rhage after  24  hours,  and  the  tubes  were  removed  the  next  day.  The  pa- 
tient was  up  in  a  chair  on  the  third  day,  and  walked  at  the  end  of  a  week. 
The  urine  did  not  pass  through  the  penis  until  the  13th  day,  but  the  fis- 
tula closed  completely  on  the  18th  day.  He  began  to  have  control  on  the 
tenth  day,  and  was  discharged  from  the  hospital  on  the  22d  day.    At  that 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  351 

time  he  was  able  to  retain  his  urine  for  three  hours,  voided  in  a  large 
stream  without  pain,  and  his  general  health  was  excellent. 

Novem'ber  30,  1905. — Letter.  I  void  urine  naturally,  four  or  five  times 
during  the  day  and  three  or  four  times  at  night,  from  one-half  to  one 
pint  at  a  time.  The  wound  is  closed  and  I  consider  myself  cured.  I  have 
had  no  erections.  (These  were  absent  before  operation).  My  general 
health  is  good. 

May  9,  1906. — Letter.  I  am  cured.  I  void  urine  naturally  and  at 
normal  intervals  during  the  day,  but  often  three  or  four  times  at  night. 
My  general  health  is  good,  and  I  have  gained  in  weight. 

Pathological  report. — ;The  specimen,  G.  U.  165,  consists  of  the  three  lobes 
of  the  prostate  removed  in  five  pieces,  and  weighs  about  65  gm.  The  me- 
dian lobe  is  the  largest,  has  been  removed  in  one  piece,  and  measures 
6x5  X  2.5  cm.  in  size.  It  is  smooth,  globular,  has  no  mucous  membrane 
attached  to  it,  and  on  section  shows  gland  tissue  with  little  intervening 
stroma.  The  lateral  lobes  have  been  removed,  each  in  two  pieces,  and  are 
each  about  3  cm.  in  diameter.  They  are  fairly  smooth  and  on  section 
show  more  stroma  than  the  median  lobe.  No  mucous  membrane,  no  ejac- 
ulatory  ducts,  no  calculi. 

Microscopic  examination. — The  picture  in  all  three  lobes  is  that 
of  a  very  glandular  tissue  arranged  in  spherical  lobules.  The 
acini  are  for  the  most  part  small,  with  occasionally  very  regular 
lumina,  and  here  and  there  is  seen  one  considerably  dilated.  The 
epithelium  lining  the  acini  is  of  the  usual  tall  cylindrical  type,  in 
places  growing  out  into  the  lumina  of  the  ducts  in  solid  tufts  of  cells. 
The  stroma  is  for  the  most  part  very  compact,  although  here  and 
there  seems  rather  loosely  bound.  It  is  composed  of  muscle  and  fibrous 
tissue  in  varying  proportions.  Quite  frequently  one  sees  well  marked 
concentric  bands  of  muscle  fibers  closely  encircling  the  acini.  Here  and 
there  in  the  stroma  are  areas  of  round  cell  and  polynuclear  infiltration 
with  occasional  evidence  of  peri  glandular  and  interstitial  inflammatory 
tissue.  Occasionally  one  sees  quite  numerous  pus  cells  in  the  lumen  of  an 
acinus  and  not  infrequently  some  in  acini  which  show  no  inflammatory 
process  either  in  the  the  parenchyma  or  its  immediate  vicinity. 

The  hypertrophy  is  of  a  distinctly  adenomatous  type  with  practically  no 
cystic  degeneration,  and  with  a  comparatively  small  amount  of  flbro-mus- 
cular  stroma. 

Case  93. — Fairly  large  hypertrophy.  Catheter  life  seven  years.  Cured. 
Followed  one  year. 

No.  908.     W.  H.  B.,  widowed,  age  76,  admitted  April  25,  1905. 

Complaint. — "  Prostatic  hypertrophy.     Catheterism." 

No  history  of  gonorrhoea  or  previous  urinary  trouble.  Onset  13  years 
ago  with  slight  increased  frequency  of  urination.  In  1896  began  to  use  a 
catheter  occasionally.  Retention  of  urine  has  been  complete  for  the  past 
10  months  and  the  catheter  employed  two  to  four  times  during  the  day. 


352  Hugh  H.  Young. 

He  has  no  pain,  but  finds  the  catheter  an  unbearable  nuisance,  and  at  times 
difficult  to  introduce.  Pain  is  not  a  marked  symptom.  Erections  have 
been  absent  for  the  past  two  years. 

Examination. — ^A  vigorous  looking  man  for  his  age.  There  is  slight  ar- 
teriosclerosis. Pulse  regular  and  80  to  the  minute.  A  slight  systolic 
murmur  at  apex  of  heart.    Lungs  and  abdomen  negative. 

Rectal  examination.— 'The  prostate  is  considerably  hypertrophied,  form- 
ing a  globular  mass  the  size  of  an  orange.  It  is  round,  smooth,  elastic 
and  without  induration  or  tenderness.  No  enlarged  glands  are  present. 
Both  epididymes  are  indurated. 

Urinalysis. — Slightly  cloudy,  sp.  gr.  1024.  Albumin  considerable,  no 
sugar,  acid,  pus  cells  and  cocci  in  large  numbers.    Urea  21  gm.  to  the  liter. 

Cystoscopic  examination. — A  silver  ca,theter  enters  with  ease.  The  blad- 
der capacity  is  large,  tonicity  is  good,  retention  of  urine  is  complete.  The 
cystoscope  shows  a  slight  enlargement  of  the  right  lateral  lobe,  a  very 
prominent  intravesical  hypertrophy  of  the  left  lobe,  projecting  anteriorly, 
and  small  rounded  median  lobe.  The  bladder  is  considerably  trabeculated 
with  small  pouches,  but  no  diverticula.  The  ureters  cannot  be  seen  on 
account  of  the  middle  lobe.  No  calculus  is  present.  With  the  finger  in 
the  rectum  and  cystoscope  in  the  urethra  the  beak  is  easily  felt,  and  the 
thickness  of  the  posterior  commisure  is  only  slightly  greater  than  nor- 
mal (cystoscope  in  sulcus  to  one  side  of  middle  lobe). 

Preliminary  treatment. -^The  patient  was  instructed  to  take  urotropin 
and  to  drink  water  in  abundance,  and  to  return  later  for  operation.  Nitro 
glycerine  and  nitrites  for  two  days  previous  to  operation  on  account  of 
high  blood  pressure,  210  mm. 

Operation,  May  22,  1905. — Ether.  Perineal  prostatectomy  by  the  regular 
technique.  The  median  lobe  was  removed  through  one  of  the  lateral  cavi- 
ties and  was  about  the  size  of  a  cherry.  The  lateral  lobes  were  moder- 
ately enlarged.  The  ejaculatory  bridge  and  floor  of  the  urethra  were  pre- 
served intact,  and  only  a  small  linear  tear  was  made  in  the  lateral  walls 
of  the  urethra,  the  bladder  was  not  torn.  There  was  very  little  hemor- 
rhage, and  the  patient  stood  the  operation  well.  Closure,  as  usual,  with 
double  tube  drainage  and  continuous  intravesical  irrigation  before  leaving 
the  table  and  after  return  to  the  ward.  Submammary  infusion  was  given 
after  the  operation.  At  beginning  of  operation  pulse  85,  blood  pressure 
180,  at  end  of  operation  pulse  65,  blood  pressure  125. 

Convalescence. — ^The  patient  reacted  well.  The  gauze  drainage  was  re- 
moved on  the  next  day  and  the  tubes  on  the  second  day,  continuous  irriga- 
tion having  been  maintained  over  night.  The  perineal  fistula  closed  on 
the  twenty-first  day.  No  epididymitis  or  other  complications  occurred. 
Highest  temperature  100.8°  on  second  day  after  operation. 

June  20,  1905. — -Patient  drinks  two  quarts  of  water  a  day  and  voids  from 
11  to  24  times.  Has  no  incontinence,  but  when  bladder  becomes  full  the 
sphincter  is  a  little  weak.  The  wound  is  tightly  healed.  The  urine  Is 
clear,  acid,  and  contains  only  a  few  pus  cells  and  bacteria.    A  silver  cath- 


study  of  14-5  Cases  of  Perineal  Prostatectomy.  353 

eter  passes  with  ease  and  finds  22  cc.  residual  urine.  There  is  no  evidence 
of  stricture  and  patient  has  not  been  instrumented  since  the  operation. 
Patient  left  the  hospital  on  the  33d  day. 

Septem'ber  23,  1905. — 'Letter.  It  is  now  four  months  since  the  operation. 
All  has  gone  well  in  every  way.  I  have  satisfactory  retention  of  urine, 
only  occasionally  the  merest  dribble  of  a  few  drops,  apparently  due  to 
nervtjus  causes.     I  am  riding  my  bicycle. 

iJVovem&er  21,  1905. — 'I  have  satisfactory  control  of  my  urine.  There 
has  been  a  slight  return  of  erections  and  my  general  health  is  excellent. 
I  have  perfect  freedom  from  a  load  of  discomfort  under  which  I  had  been 
for  years,  and  have  a  new  lease  on  life. 

November  30,  1905. — 'Letter.  I  void  urine  naturally  about  10  times  in 
the  day  and  once  or  twice  at  night,  rarely  over  325  cc.  at  a  time,  occasion- 
ally 400  cc.  I  suffer  no  pain,  the  wound  has  remained  healed.  I  have  in- 
complete erections.  My  general  health  is  excellent.  Last  night  I  slept 
seven  and  one-half  hours  without  urinating. 

May  7,  1906. — The  wound  has  remained  closed.  I  void  urine  naturally, 
and  at  normal-  intervals,  from  300  to  350  cc.  at  a  time.  I  have  no  pain, 
have  semi-erections,  have  not  attempted  intercourse.  I  have  had  no  com- 
plications nor  medical  treatment.  My  general  health  is  excellent  and  I  con- 
sider myself  cured. 

May  22,  1906. — Letter.  It  is  a  year  since  the  operation.  I  pass  my  urine 
naturally,  have  satisfactory  control,  and  only  dribble  occasionally  (at  in- 
tervals of  days)  when  convenient  opportunity  of  relief  is  poor  and  when 
the  bladder  gets  too  full.  The  intervals  are  between  four  and  five  and 
one-half  hours,  and  the  amounts  voided  from  200  to  300  cc. 

Pathological  report. — The  specimen,  G.  U.  166,  consists  of  the  three  lobes 
of  the  prostate  removed  in  five  pieces,  and  weighing  about  30  gm.  The 
left  lateral  lobe  measures  3  x  3  x  1.7  cm.,  is  fairly  smooth  and  on  section 
shows  gland  tissue  and  a  considerable  amount  of  stroma.  The  right  lobe 
measures  3.5  x  2.5  x  1.7  cm.,  and  has  been  removed  in  two  pieces,  is  some- 
what torn  and  irregular,  and  is  apparently  more  fibrous  than  the  left.  One 
dilated  cyst  seen.  The  median  lobe  forms  a  globular  mass  about  2  cm.  in 
diameter  and  has  been  removed  in  two  pieces.  It  is  apparently  more 
glandular  than  the  lateral  lobes.  No  mucous  membrane,  no  ducts,  no  cal- 
culi removed. 

Microscopic  examination. — This  shows  in  the  middle  and  left 
lateral  lobe  an  adenomatous  hypertrophy  in  which  the  gland 
tissue  is  largely  arranged  in  lobules.  In  areas  many  of  the 
acini  are  very  much  dilated  and  lined  with  a  single  layer  of 
flattened  epithelium.  In  areas  they  are  about  normal  in  size,  and  again 
in  other  areas  somewhat  dilated  with  irregular  lumina.  The  gland  tissue 
is  very  much  in  excess  of  the  stroma,  which  is  of  a  fairly  compact  nature. 
Surrounding  the  glandular  lobules  the  stroma  is  fairly  compact,  and  its 
contained  ducts  are  very  much  compressed.  The  stroma  is  composed  of 
both  muscle  and  fibrous  tissue;  the  fibrous  tissue  somewhat  predominating. 
Here  and  there  is  some  round  cell  infiltration.     The  right  lobe  is  also 


354  Hugli  H.  Young. 

distinctly  adenomatous  in  nature,  but  its  ducts  show  practically  no  cystic 
degeneration,  and  there  are  distinct  areas  of  connective  tissue  hypoplasia. 
It  contains  more  stroma  than  either  the  middle  or  left  lobe. 

Case  94. — Slight  enlargement  of  lateral  lobes.  Cystin  calculus.  Con- 
tracted bladder.     Cured. 

No.  913.    W.  B.  E.,  age  67,  married,  admitted  April  27,  1905. 

Complaint. — "  Enlarged  prostate." 

The  patient  never  had  gonorrhoea. 

Present  illness  began  about  one  year  ago  with  slight  increase  in  the  fre- 
quency of  urination.  About  six  months  ago  he  began  to  have  a  sharp  pain 
in  the  glans  penis  at  the  end  of  micturition.  He  has  never  had  retention 
of  urine  and  no  catheter  has  been  introduced.  He  has  been  unable  to 
have  sexual  intercourse  for  one  and  one-half  years. 

S.  P. — 'Voids  once  or  twice  at  night  and  six  or  eight  times  during  the 
day.  Micturition  accompanied  by  pain  at  the  end  of  the  penis,  and  slight 
tenesmus. 

Examination. — The  patient  is  a  sturdy  looking  man.  Heart,  lungs,  and 
abdomen  are  negative.  The  prostate  is  enlarged  in  both  lateral  lobes,  the 
left  being  the  larger.  The  median  furrow  and  notch  are  wide  and  deep. 
The  general  contour  is  rounded,  smooth,  fairly  hard,  but  no  nodules  are 
present  and  there  is  no  induration  in  the  region  of  the  seminal  vesicles. 
The  prostatic  secretion  contains  a  few  pus  cells,  a  large  number  of  gran- 
ule cells  and  very  few  lecithins.  The  urine  is  slightly  cloudy,  acid,  albu- 
min present,  no  sugar.  Urea  13  gm.  to  the  liter.  Microscopically  pus  cells 
and  a  few  bacteria. 

Cystoscopic  exam,ination. — Coude  catheter  passes  with  ease  and  finds  15 
cc.  residual  urine.  The  bladder  is  contracted,  holding  only  160  cc.  The 
cystoscope  shows  a  slight  hypertrophy  of  the  median  portion  in  the  shape 
of  a  small,  rounded  lobe.  The  lateral  lobes  are  only  slightly  enlarged.  In 
the  bladder  is  seen  a  small  oval  calculus  with  a  coarsely  granular  surface 
composed  of  yellowish  crystals. 

Operation,  May  22,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  slightly  enlarged,  measuring  2  x  2% 
X  3  cm.  in  size.  The  urethra  and  bladder  were  not  torn  in  their  removal. 
The  tractor  was  then  removed  and  the  urethra  split  along  its  left  lateral 
wall,  the  vesical  orifice  dilated,  the  stone  forceps  introduced  and  an  oval 
calculus  1.0  X  2  X  3  cm.  in  size  removed.  It  is  roughly  granular,  its  sur- 
face being  composed  of  numerous  crystalline  spicules,  amber  in  color  and 
very  hard  (chemical  examination  showed  it  to  be  composed  of  pure  cys- 
tin). Insertion  of  the  finger  after  the  removal  of  the  calculus  showed  no 
enlargement  of  the  median  portion  of  the  prostate.  It  had  apparently  been 
sufficiently  removed  with  the  lateral  lobes.  The  lateral  cavities  were 
packed  with  gauze.  Double  catheter  was  inserted  into  the  bladder  through 
the  perineum  and  the  wound  closed  as  usual.  Submammary  infusion  and 
continuous  irrigation  on  return  to  ward. 

Convalescence. — The  patient  reacted  well.     The  gauze  was  removed  in 


study  of  145  Cases  of  Perineal  Prostatectomy.  355 

36  hours  and  the  tubes  in  48.  Urine  began  to  come  through  the  penis  on 
the  fifth  day  and  the  fistula  closed  on  the  18th.  He  was  out  of  bed  on 
the  fifth  day,  but  did  not  walk  until  the  eighth.  Highest  temperature 
100.2°  on  third  day  after  operation,  after  that  normal. 

June  14,  1905. — -The  patient  voids  urine  freely  in  a  good  stream  at  inter- 
vals of  from  three  to  five  hours  during  the  day  and  only  once  at  night. 
Has  good  control,  no  dribbling,  slight  precipitancy  at  times.  A  coude 
catheter  passes  easily,  there  is  no  residual  arine.  The  urine  is  cloudy  and 
contains  a  few  pus  cells  and  bacteria.  Discharged  from  the  hospital  on 
the  24th  day. 

July  5,  1905. — Letter.  Yesterday  I  passed  a  small  calculus  without  pain 
or  hemorrhage. 

November  30,  1905. — Letter.  I  void  urine  naturally  and  consider  myself 
cured.  I  have  no  pain  and  often  void  a  pint  at  a  time.  I  urinate  two  or 
three  times  at  night  and  six  or  seven  times  during  the  day.  I  have  no 
erections,  but  these  were  absent  before  the  operation. 

May  8,  1906. — Letter.  I  void  urine  naturally,  once  during  the  night  and 
at  normal  intervals  during  the  day,  and  occasionally  void  a  pint  of  urine  at 
a  time.  I  have  no  pain.  .  Erections  are  partial.  I  have  not  attempted 
sexual  intercourse.  My  general  health  is  good.  I  have  gained  in  weight 
and  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  163,  consists  of  the  two  lateral 
lobes  of  the  prostate,  each  in  one  piece  and  weighing  all  about  15  gm. 
The  right  lobe  measures  3  x  2.5  x  2  cm.  is  fairly  smooth,  encapsulated,  and 
on  section  shows  considerable  gland  tissue  with  dilated  acini.  The  left 
lobe  measures  2.5  x  2.3  x  2  cm.,  and  contains  a  cavity  about  5  mm.  in  diam- 
eter from  which  a  calculus  has  been  removed.  The  cut  surface  shows 
gland  tissue  with  very  little  stroma,  no  cystic  dilatations,  and  one  or  two 
seed  calculi.  No  mucous  membrane  or  ejaculatory  ducts  have  been  re- 
moved. 

Microscopic  exaviination. — The  hypertrophy  is  of  the  glandular  type 
with  some  arrangement  in  lobules.  The  gland  acini  show  the  usual  dila- 
tation with  complexity  of  the  lumina  and  areas  of  cystic  degeneration. 
There  is  present  much  endoglandular  sprouting.  The  stroma  contains 
very  much  more  fibrous  tissue  than  muscle.  Some  areas  of  prostatitis 
and  numerous  corpora  amylacea  are  seen. 

Case  95. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Complete 
retention.    Catheter  life.    Cured.    Followed  12  months. 

No.  937.     T.  S.  N.,  age  59,  married,  admitted  May  5,  1905. 

Complaint. — •"  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  three  years  ago  with  burning  pain  on  urina- 
tion, slight  hesitation  and  some  straining.  He  had  no  particular  incon- 
venience until  two  years  ago  when  urination  became  quite  frequent  and 
difficult.  In  a  few  weeks  he  was  voiding  every  hour  night  and  day.  He 
had  no  acute  retention  of  urine,  but  on  the  advice  of  a  physician  he  began 


356  Hugh  H.  Young. 

the  use  of  a  catheter  now  almost  two  years  ago,  and  since  then  has  been 
unable  to  void  naturally  except  small  amounts  very  occasionally.  About 
nine  months  ago  he  had  epididymitis  on  the  left  side,  and  since  then  three 
other  attacks  on  this  side  and  one  on  the  right.  He  has  never  had  hema- 
turia nor  passed  a  calculus.  His  general  health  is  excellent,  his  sexual 
powers  are  good. 

)S.  P. — A  catheter  is  used  three  or  four  times  a  day.  He  suffers  no  pain, 
has  no  hematuria,  and  his  general  health  is  excellent  and  he  begs  to  be 
relieved  of  the  catheter  life. 

Examination. — The  patient  is  well  nourished  with  mucous  membranes 
of  good  color.  His  chest  and  abdomen  are  negative.  Genitalia:  Both  epi- 
didymes  are  hard  and  tender. 

Rectal  examination. — >The  prostate  is  only  moderately  enlarged.  It  is 
smooth,  soft,  globular  in  shape  and  is  not  tender.  Extending  upward  and 
outward  from  the  upper  end  of  the  prostate  on  each  side  is  a  smooth,  hard 
cord  about  the  size  of  a  small  lead  pencil,  the  upper  limits  of  which  are 
impossible  to  reach.  The  diagnosis  of  indurated  vasa  deferentia  is  made. 
Seminal  vesicles  are  not  palpable;  there  are  no  glands  to  be  felt. 

Urinalysis. — Slightly  cloudy,  acid,  sp.  gr.  1016,  no  albumin,  no  sugar. 
Urea  15  gm.  to  the  liter.    Microscopically  pus  cells  and  bacilli. 

Cystoscopic  examination. — The  patient  has  complete  retention  of  urine. 
Bladder  capacity  600  cc.  Tonicity  good.  A  stricture  of  large  caliber  is 
present  one  inch  from  the  meatus,  which  grips  the  cystoscope.  The  cysto- 
scope  shows  a  small  round  median  lobe  with  a  deep  sulcus  on  each  side 
and  very  little  intravesical  hypertrophy  of  the  lateral  lobes.  A  small  polyp 
is  seen  attached  to  the  right  lateral  lobe,  the  mucous  membrane  elsewhere 
is  smooth  and  regular.  The  bladder  is  markedly  trabeculated,  but  only 
slightly  inflamed.  There  are  numerous  cellules  and  diverticula  on  the  pos- 
terior and  lateral  walls,  but  no  foreign  bodies  are  present.  The  ureters 
cannot  be  seen  on  account  of  the  middle  lobe.  With  the  finger  in  the  rec- 
tum and  cystoscope  in  the  urethra  the  amount  of  the  tissue  is  not  greatly 
increased.     (Cystoscope  in  one  of  the  sulci.) 

Operation,  May  22,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  which  were  only  moderately  hypertrophied 
were  easily  enucleated,  each  in  one  piece.  The  median  bar  was  removed  in 
two  pieces,  one  through  each  lateral  cavity.  It  was  impossible  to  engage 
the  small  median  lobe  with  the  blade  of  the  tractor  which  was  therefore 
withdrawn  and  the  finger  inserted  through  the  urethra  to  push  the  middle 
lobe  into  the  left  lateral  cavity  where  it  was  easily  enucleated.  Urethra 
was  torn  on  each  side,  but  no  mucous  membrane  was  removed,  and  the 
floor  of  the  urethra  and  ejaculatory  ducts  were  preserved  intact.  The 
wound  was  closed  as  usual  with  double  catheter  drains  and  light  packs  for 
the  lateral  cavities.  An  infusion  was  given  on  return  to  the  ward  and 
continuous  vesical  irrigation  begun.  The  patient  stood  the  operation  well. 
Pulse  varying  from  95  to  115,  110  on  return  to  the  ward. 

Convalescence. — The  patient  convalesced  rapidly.    The  temperature  did 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  357 

not  rise  above  100°.  The  gauze  was  removed  after  24  hours  and  the  tubes 
in  48  hours.  Urine  began  to  come  through  the  penis  on  the  fifth  day.  He 
had  good  control  on  the  eighth  and  by  the  twelfth  day  could  retain  urine 
for  several  hours.  The  perineal  fistula  closed  on  the  fifteenth  day.  He  was 
out  of  bed  on  the  third  day,  and  began  to  walk  in  the  first  week.  Erections 
returned  on  the  fourteenth  day.  On  the  twentieth  day  a  catheter  was  in- 
troduced and  found  40  cc.  residual  urine.  He  was  discharged  from  the 
hospital  on  the  twentieth  day. 

June  19,  1905. — The  patient  is  in  excellent  condition.  Retains  urine  for 
five  hours  during  the  night  and  four  hours  during  the  day.  The  stream 
is  large,  there  is  no  hesitation  and  no  incontinence.  The  perineal  wound 
is  closed.  A  large  silver  catheter  passes  with  ease,  no  obstruction  is  pres- 
ent, residual  urine  10  cc. 

Novem'ber  30,  1905. — Letter.  I  void  urine  naturally  three  or  four  times 
during  the  day  and  rarely  ever  more  than  once  at  night,  from  12  to  16 
ounces  at  a  time.  Occasionally  I  have  a  slight  pain  when  urinating.  The 
fistula  is  closed.  Erections  have  returned  but  are  only  partial.  I  have 
had  sexual  intercourse,  but  the  ejaculation  is  slight  and  not  entirely  satis- 
factory.    My  general  health  is  excellent. 

May  10,  1906. — Letter.  I  void  urine  naturally  as  much  so  as  when  a  boy, 
at  normal  intervals  and  very  rarely  have  to  get  up  at  night.  I  have  no 
pain,  no  incontinence,  no  fistula.  Erections  have  returned  and  I  have 
sexual  intercourse,  not  quite  as  satisfactory  as  before.  I  consider  myself 
perfectly  cured.     My  recovery  seems  like  a  miracle. 

Pathological  report. — The  specimen,  G.  U.  167,  consists  of  the  three  lobes 
of  the  prostate  removed  in  four  pieces  and  weighs  about  Gr-20.  The  left 
lobe  measures  2.5  x  2.5  x  1.5  cm.,  is  fairly  smooth  with  considerable  capsule, 
and  on  section  shows  an  abundance  of  gland  tissue  and  a  small  amount  of 
stroma.  The  right  lobe  measures  3.5  x  2  x  1.5  cm.,  and  is  similar  in 
character  to  the  left.  The  median  lobe  has  been  removed  in  two  pieces 
each  about  2.5  x  1.5  x  1  cm.  in  size,  one  of  which  formed  a  pedunculated 
intravesical  lobe,  oval  in  shape,  but  contains  no  mucous  membrane.  No 
ejaculatory  ducts  or  calculi  removed. 

Microscopic  examination. — Both  lateral  lobes  and  the  middle  lobe  show 
practically  the  same  type  of  hypertrophy,  which  is  a  distinctly  adenoma- 
tous one.  The  gland  tissue  is  arranged  somewhat  in  lobules,  and  there 
is  considerable  dilatation  of  the  culs-de-sac.  The  majority  of  the  acini 
show  a  considerable  complexity  due  to  the  folding  and  papillomatous  out- 
growth of  the  lining  walls.  The  epithelium  is  of  a  tall  cylindrical  type, 
in  places  of  one  layer  deep,  and  others  many  layers,  and  again  growing 
out  in  apparently  solid  epithelial  masses  into  the  lumen.  The  stroma  is 
fairly  compact,  and  composed  of  more  fibrous  than  muscle  tissue.  The 
gland  tissue  is  very  much  more  in  excess  than  the  stroma.  There  is  con- 
siderable round  cell  infiltration  in  various  areas.  This  infiltration  is 
mostly  limited  to  the  interstitial  tissue,  although  in  a  few  areas  being 
most  marked  about  the  acini. 


358  Hugh  H.  Young. 

Case  96. — Very  large  prostate  with  great  median  lobe,  with  villous  sur- 
face. Diagnosis,  malignant.  Suprapubic  drainage.  Later  perineal  pros- 
tatectomy.   Cure. 

No.  944.     J.  C,  age  68,  married,  admitted  September  29,  1904. 

Complaint. — "  Prostatic  hypertrophy,  catheterism." 

The  patient  had  never  had  gonorrhoea. 

Present  illness  began  14  years  ago  when  the  patient  noticed  a  slight 
difficulty  and  increased  frequency  of  urination.  The  first  retention  of 
urine  came  on  12  years  ago.  Since  then  the  catheter  has  been  used  at 
irregular  intervals,  but  the  patient  has  always  been  able  to  void  a  small 
amount  naturally.  Of  late  he  has  been  suffering  pain  and  severe  spasm  in 
the  bladder  which  frequently  comes  on  10  or  12  times  a  day.  He  usually 
passes  the  catheter  as  soon  as  the  spasm  has  subsided,  and  finds  urine, 
but  sometimes  the  bladder  is  completely  empty.  He  has  had  no  pain 
in  the  back,  buttocks,  or  groins,  but  he  frequently  has  a  severe  pain  in 
both  legs  from  which  he  only  can  find  relief  in  the  kneeling  posture. 
Two  months  ago  he  had  a  considerable  hemorrhage  from  the  bladder 
which  continued  for  a  week.  There  has  been  none  since.  He  has  lost 
considerably  in  weight. 

8.  P. — The  frequency  of  urination  is  very  variable,  at  times  every  half 
hour  at  others  every  two  hours.  "When  the  desire  to  urinate  comes  on 
he  has  a  severe  pain  and  a  spasm  at  the  neck  of  his  bladder.  He  catheter- 
izes  himself  from  three  to  six  times  a  day,  but  usually  finds  only  two  or 
three  ounces  of  residual  urine. 

Sexual  powers. — ^Normal. 

Examination. — The  patient  is  a  rather  pale  looking  man.  Heart,  lungs, 
and  abdomen  negative. 

The  right  testicle  and  epididymis  are  enlarged  and  indurated.  There  is 
no  hernia  present. 

Rectal  examination. — The  prostate  is  considerably  enlarged  about  the 
size  of  a  medium  sized  orange.  Smooth,  rounded,  soft,  elastic,  no  nodules, 
no  induration.  The  median  furrow  and  notch  are  shallow.  Seminal 
vesicles  not  palpable  nor  enlarged,  but  there  is  no  induration  above  the 
prostate,  and  the  rectal  wall  is  soft  and  not  adherent  and  no  glands  are 
to  be  felt. 

Cystoscopic  examination. — A  coude  catheter  cannot  be  passed  owing  to 
obstruction  in  the  prostatic  urethra.  A  silver  catheter  passes  with  some 
difficulty  and  produces  hemorrhage  which  requires  the  use  of  adrenalin. 
Residual  urine  250  cc.  is  present.  The  cystoscope  shows  a  very  extensive 
outgrowth  from  the  prostate  on  all  sides.  The  surface  is  irregular,  in 
places  villous  in  type,  in  others  fissured,  and  in  places  frayed  out  and 
white.  On  the  left  side  the  growth  extends  far  out  into  the  bladder 
and  has  the  appearance  of  a  large  vesical  tumor,  but  examination  shows 
that  it  springs  from  the  left  lobe  of  the  prostate.  It  is  difficult  to  see 
more  than  a  small  portion  of  the  bladder  which  is  found  to  be  greatly 
trabeculated  with  numerous  diverticula.     With  the  finger  in  the  rectum 


study  of  145  Cases  of  Perineal  Prostatectomy.  359 

and  cystoscope  in  the  urethra  it  is  impossible  to  feel  the  beak  of  the 
instrument,  the  amount  of  tissue  in  the  median  portion  being  very- 
extensive. 

Urinalysis. — ^Very  purulent.  Microscopically  red  blood  cells,  pus,  bacilli, 
and  cocci.     Slightly  acid,  no  sugar,  small  amount  of  albumin. 

Remark. — The  diagnosis  of  carcinoma  of  the  prostate  with  extensive 
intravesical  tumor  outgrowth  was  made  upon  the  appearance  of  the 
intravesical  mass,  pain  and  the  loss  of  weight.  Rectal  examination  did 
not  suggest  malignant  disease. 

Operation,  September  30,  1904. — Ether.  Suprapubic  cystostomy  for 
drainage.  Examination  of  the  bladder  with  the  finger  showed  an  extensive 
outgrowth  of  the  prostate  which  filled  the  base  of  the  bladder.  Its  surface 
was  very  irregular,  fissured,  villous,  and  in  places  granular  and  quite 
firm.  The  diagnosis  of  carcinoma  seemed  entirely  confirmed,  and  ex- 
tirpation not  attempted. 

Convalescence. — The  patient  improved  rapidly  after  the  operation,  was 
up  in  a  wheel  chair  on  the  11th  day  and  discharged  on  the  28th  day.  He 
then  had  a  healthy  suprapubic  fistula  in  which  he  wore  a  hard  rubber 
tube  connected  with  a  Bloodgood  bag. 

May  19,  1905. — The  patient  returns  for  examination.  He  has  worn  the 
Bloodgood  drainage  apparatus  since  leaving  the  hospital.  He  has  had  no 
pain,  but  there  has  been  considerable  leakage  around  the  tube  and  he  is 
uncomfortable.  Hemorrhage  occurred  for  the  first  time  last  week.  He 
has  gained  15  pounds  in  weight  and  his  health  is  excellent. 

Rectal  examination. — The  prostate  is  in  the  form  of  a  smooth  globular 
mass  about  the  size  of  a  medium  sized  orange,  elastic,  fairly  soft,  and 
without  induration.  The  cystoscope  shows  an  entirely  different  picture 
around  the  prostatic  orifice.  The  villi  and  fissures  have  completely  dis- 
appeared and  there  are  present  now  two  large  lateral  lobes  connected  by 
a  fairly  large  median  bar.  The  mucous  membrane  covering  them  is 
granular,  but  not  irregular,  and  the  appearance  is  that  of  an  ordinary 
hypertrophy  and  does  not  suggest  malignancy.  Perineal  prostatectomy 
is  advised. 

Operation,  May  22,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  left  lateral  lobe,  the  median  bar  and  the  right  lateral  lobe 
were  removed  in  one  piece  without  destroying  the  fioor  of  the  urethra, 
the  right  lobe  having  been  drawn  after  the  median  bar  beneath  the 
urethra  into  the  left  lateral  cavity.  The  tractor  was  then  removed  and  a 
finger  inserted  into  the  bladder,  and  a  fairly  large  rounded  median  lobe, 
which  had  dropped  well  back  on  the  tractor  was  found.  It  was  drawn 
up  by  the  finger  until  it  presented  into  the  left  lateral  cavity  and  enucle- 
ated, but  in  doing  so  a  small  tear  was  made  in  the  mucous  membrane  cov- 
ering it.  The  ejaculatory  ducts  and  fioor  of  the  urethra  were  preserved 
intact.  The  usual  closure  was  employed,  lateral  cavities  being  packed 
with  gauze  and  double  catheter  drainage  for  the  bladder.  There  was  mod- 
erate amount  of  hemorrhage  and  the  patient  stood  the  operation  well. 
Continuous  irrigation  and  a  submammary  infusion  were  given  on  return 
to  the  ward.    Pulse  at  the  end  110. 


360  Hugh  H.  Young. 

Convalescence. — The  patient  reacted  well,  the  temperature  rose  to  101.4^ 
on  the  day  after  the  operation,  but  after  the  fourth  day  was  practically 
normal.  The  gauze  was  removed  on  the  day  after  the  operation  and  the 
tubes  on  the  next  day.  The  patient  was  up  in  a  wheel  chair  on  the 
second  day.  Urine  flowed  through  the  urethra  on  the  fifth  day.  The  supra- 
pubic fistula  closed  on  the  seventh  day,  and  the  patient  was  discharged 
on  the  32d  day.  His  general  condition  then  was  excellent,  nearly  all  of 
the  urine  passed  through  the  meatus,  a  small  fistula  was  present  in  the 
perineum.  The  perineal  fistula  closed  on  August  1,  1905,  70  days  after 
operation. 

November  30,  1905. — Letter.  I  urinate  seven  or  eight  times  during  the 
day  and  once  or  twice  at  night  and  often  pass  250  cc.  at  a  time.  I  am 
free  from  pain  and  my  general  health  is  excellent.  The  wound  is 
completely  closed,  but  there  is  a  slight  rupture  in  the  suprapubic  scar. 
I  have  no  erections.     I  have  had  a  swelling  of  the  left  testicle. 

May  7,  1906. — Letter.  I  void  urine  naturally,  in  large  amounts,  but 
more  frequently  than  normal,  seven  or  eight  times  during  the  day  and 
two  or  three  at  night,  and  about  half  a  pint  at  a  time.  I  suffer  no  pain 
and  consider  myself  cured.  I  have  erections  but  they  are  not  perfect,  and 
have  not  attempted  intercourse.  I  passed  two  calculi  last  month.  My 
health  is  excellent. 

Pathological  report. — The  specimen,  G.  U.  168,  consists  of  three  lobes 
of  the  prostate,  and  weighs  about  G-85.  The  right  and  left  lobes  and  the 
median  bar  have  been  removed  in  one  piece.  The  right  lobe  measures 
5x4x3  cm.  The  left  measures  6  x  3.5  x  3.5  cm.  and  the  median  bar 
joining  them  is  3  cm.  wide  and  2  cm.  thick.  There  is  no  mucous  membrane 
attached  to  these  lobes  which  are  irregular  along  the  urethra,  but  smooth 
externally.  The  median  lobe  has  been  removed  separately  in  two  pieces, 
measuring  5x3x3  cm.  and  2  x  2  x  1.5  cm.  in  size  respectively.  On  section 
there  is  considerable  glandular  tissue  with  small  amount  of  stroma. 
No  induration  or  areas  suggesting  malignancy.  No  mucous  membrane, 
no  ejaculatory  ducts  and  no  calculi  have  been  removed. 

Microscopic  examination. — The  lateral  lobes  show  an  adenomatous  type 
of  hypertrophy.  The  ducts  in  many  lobules  show  much  cystic  degenera- 
tion with  flattening  of  the  epithelium.  In  other  areas  the  ducts  are  not 
so  much  dilated,  but  there  is  very  marked  complexity  of  the  gland.  The 
stroma  is  in  places  fairly  thick,  and  in  other  areas,  where  the  gland  tissue 
is  particularly  abundant,  is  composed  of  slender  bands.  The  stroma  is 
rather  dense,  and  composed  for  the  most  part  of  muscle  and  fibrous  tissue 
in  fairly  equal  parts.  In  a  few  limited  areas  there  is  some  round  cell  and 
polynuclear   infiltration. 

The  middle  lobe  contains  distinctly  less  gland  tissue  than  the  lateral 
lobes,  and  there  is  considerable  connective  tissue  hyperplasia.  The  ducts, 
which  are  present,  are  for  the  most  part  undilated  although  here  and  there 
one  finds  a  few  acini  which  have  undergone  cystic  degeneration. 

This  is  distinctly  an  adenomatous  type  of  hypertrophy  in  the  lateral 
lobes,  while  the  middle  lobe  is  less  adenomatous,  and  contains  considerably 
more  fibrous  tissue  than  the  lateral  lobes. 


study  of  lJi.5  Cases  of  Perineal  Prostatectomy.  361 

Case  97. — Moderate  hypertrophy  of  median  and  right  lateral  lohes. 
Great  hypertrophy  of  the  left  lateral  lobe,  with  intravesical  villi  suggesting 
malignancy.    Suprapubic  exploration.    Perineal  prostatectomy.     Cure. 

No..  894.     J.  L.    McW.,  age  61,  married,  admitted  April  24,  1905. 

Complaint. — "  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  six  years  ago  with  difficulty  of  urination  which 
gradually  increased  and  five  years  ago  complete  retention  of  urine  set 
in  and  he  had  to  be  catheterized.  After  that  the  patient  was  able  to 
void,  but  urinated  frequently  and  in  a  small  stream.  On  January  29,  1905, 
retention  of  urine  came  on  a  second  time,  and  as  his  physician  was  unable 
to  pass  a  catheter,  suprapubic  aspiration  was  performed.  Later  a  silver 
catheter  with  a  large  curve  was  passed,  but  in  a  short  time  the  patient 
was  able  to  void  again  and  has  not  been  catheterized  since. 

S.  P. — Urination  three  times  during  the  night,  four  times  during  the 
day.  Urine  difficult  to  start,  stream  small  and  slow,  slight  dribbling  at 
end.  No  blood,  no  pain,  general  health  excellent.  Sexual  powers  are  weak. 
Erections  imperfect.    Sexual  desire  about  normal. 

Examination. — Patient  is  a  well  nourished  man,  lips  and  mucous 
membranes  of  good  color.    Heart,  lungs,  and  abdomen  negative. 

Rectal  examination. — The  prostate  is  considerably  enlarged,  being  about 
the  size  of  a  medium-sized  orange.  It  is  smooth,  rounded,  soft,  there  are 
no  areas  of  induration  and  no  nodules,  and  the  upper  end  is  reached  with 
difficulty.  Seminal  vesicles  are  not  palpable,  but  there  is  no  induration 
in  this  region.  The  prostatic  secretion  contains  a  few  pus  cells,  granule 
cells,  spermatozoa  and  a  few  lecithin  bodies. 

Urinalysis. — Clear,  acid,  sp.  gr.  1022,  no  albumin,  no  sugar,  urea  13  gr. 
to  th6  liter.    Microscopically  red-blood  corpuscles,  no  pus  cells,  no  bacteria. 

Cystoscopie  examination. — A  coude  catheter  passes  with  ease  and  finds 
40  cc.  residual  urine  and  a  bladder  capacity  320  cc.  The  cystoscope  shows 
a  moderate  enlargement  of  the  median  lobe  and  a  fairly  considerable  intra- 
vesical enlargement  of  the  left  lateral  lobe.  The  right  lateral  lobe  is 
only  slightly  enlarged  intravesically.  The  surface  of  the  median  lobe  is 
irregular  and  one  large  polypoid  mass  is  seen  attached  to  its  posterior 
surface.  Looking  upward  and  to  the  left  several  irregular  fissures  are 
seen.  There  are  no  definite  villi  and  no  ulcerations,  and  the  bladder 
wall  is  trabeculated  and  shov/s  no  evidence  of  infiltration.  The  cystoscopie 
examination  suggests  malignancy  owing  to  the  irregularly  lobulated 
and  fissured  condition  of  the  intravesical  portion  and  the  adherent  polyps, 
but  rectal  examination  does  not  at  all  suggest  malignancy.  The  history 
is  also  against  malignancy,  but  in  order  to  be  certain  it  is  thought  best 
to  perform  a  suprapubic  cystostomy  for  exploration  previous  to  prostat- 
ectomy through  the  perineum. 

Operation,  April  28,  1905. — Suprapubic  cystotomy  for  vesical  examination. 
Diagnosis,  benign  hypertrophy.  Closure  of  the  bladder  with  three  inter- 
rupted sutures.  Partial  closure  of  the  abdominal  wound  with  catgut.  The 
Vol.  XIV.— 24. 


362  Hugh  H.  Young. 

patient  was  then  placed  in  the  lithotomy  position  and  perineal  prostat- 
ectomy performed  by  the  usual  technique.  The  left  lateral  lobe  was  found 
to  be  greatly  hypertrophied  measuring  5x6x8  cm.  in  size.  It  was  quite 
adherent  to  the  urethra  and  to  the  bladder,  but  was  enucleated  without 
removing  any  of  the  mucous  membrane.  The  right  lateral  lobe  was  much 
smaller  measuring  2x3x4  cm.  in  size,  and  attached  to  it  was  the  median 
lobe  which  was  enucleated  in  one  piece  with  it.  A  small  tear  was  made 
in  the  urethra  but  no  mucous  membrane  was  removed  and  the  ejaculatory 
ducts  were  preserved.  The  wound  was  closed  as  usual  with  double  catheter 
drainage  and  light  packs  for  the  lateral  cavities.  Saline  infusion  on 
return  to  ward,  no  continuous  irrigation  on  account  of  suprapubic  suture 
of  vesical  wound.  The  patient  stood  the  operation  well.  The  hemorrhage 
was  slight.    Pulse  at  the  end  95,  one  hour  later  88. 

Convalescence. — Patient  reacted  well  and  the  temperature  rose  to  106.6° 
the  day  after  the  operation,  but  was  normal  on  the  third  day.  The  gauze 
packs  were  removed  from  the  perineal  and  suprapubic  wounds  in  48 
hours  and  the  tubes  the  same  day.  The  suprapubic  vesical  wound  did  not 
leak,  the  abdominal  wound  healing  nicely  by  granulation.  No  urine 
came  through  the  penis  until  the  15th  day.  After  that  the  perineal 
fistula  closed  slowly,  but  a  few  drops  escaped  through  it  on  his  discharge 
on  the  24th  day.  Interval  urination,  however,  had  been  present  since  the 
removal  of  the  perineal  tubes,  and  he  was  able  to  retain  his  urine  three 
hours  and  had  no  incontinence.  A  silver  catheter  passed  with  ease,  no 
stricture  or  other  obstruction,  no  residual  urine  present.  The  fistula  was 
curetted  and  the  patient  was  discharged.  Urine  contained  a  few  pus 
cells  and  bacilli.  Before  leaving  patient  reported  that  he  had  several 
erections.  Owing  to  suprapubic  wound  the  patient  was  confined  to  his  bed 
for  two  weeks.    The  perineal  fistula  closed  on  the  30th  day. 

February  8,  1906. — Urination  is  entirely  satisfactory,  three  times  during 
day  and  twice  at  night,  four  or  five  ounces  at  a  time,  entirely  without  pain. 
I  have  erections  but  very  seldom  and  rather  weak.  I  have  sexual  inter- 
course occasionally,  but  the  ejaculation  is  slow  and  the  emission  scant. 

May  7,  1906. — Letter.  I  void  urine  naturally  three  times  during  the 
day  and  about  twice  at  night,  about  six  ounces  at  a  time.  I  have  no  pain. 
I  have  erections,  but  not  as  firm  as  normal  and  the  ejaculation  is  slow. 
I  have  had  intercourse  occasionally.  My  general  health  is  excellent,  I  have 
gained  in  weight  and  consider  myself  cured. 

September  14,  1906. — Letter.  The  perineal  wound  has  remained  closed. 
I  void  urine  naturally  five  times  in  24  hours  and  consider  myself  cured. 
I  have  erections  and  sexual  intercourse.    My  general  health  is  excellent. 

Pathological  report. — The  specimen,  G.  U.  150,  consists  of  two  pieces, 
the  two  lateral  lobes  and  weighs  about  G-60.  The  left  lateral  lobe  is  smooth, 
oval,  slightly  lobulated  mass  7  x  5  x  4.5  cm.  in  size,  and  on  section  shows 
a  very  thin  capsule,  moderate  amount  of  gland  tissue  and  considerable 
stroma  with  few  dilated  ducts.  The  right  lateral  lobe  is  much  smaller, 
measuring  6x3x3  cm.  in  size,  and  is  similar  in  appearance  to  the  left. 
No  mucous  membrane,  no  ducts,  no  calculi. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  363 

Microscopic  examination. — This  hypertrophy  is  of  the  usual  glandular 
type  with  areas  of  gland  aggregation.  The  acini  are  for  the  most  part 
dilated,  and  there  is  present  a  considerable  amount  of  endoglandular  papil- 
lomatous growth.  Some  glandular  and  interstitial  prostatitis  is  present 
with  small  accumulations  of  inflammatory  cells  at  several  points  almost 
suggesting  small  abscesses.  The  stroma  is  about  two-thirds  fibrous  tissue 
although  there  are  areas  where  the  muscle  element  is  equal  to,  if  not  in 
excess  of,  the  connective  tissue. 

Case  98. — Moderate  hypertrophy  of  median  and  lateral  lobes  Cure. 
Followed  11  months. 

No.  1001.  M.  S.,  age  60,  married,  admitted  June  3,  1905,  St.  Francis 
Hospital,  La  Crosse,  Wisconsin. 

Complaint. — "  Frequent  urination." 

No  history  of  gonorrhcea. 

Present  illness  began  eight  years  ago  with  hesitation  at  beginning  of 
urination,  and  straining.  Urination  gradually  became  more  frequent,  and 
he  now  urinates  about  10  times  at  night  and  every  hour  during  the  day. 
There  is  an  occasional  burning  sensation  at  the  end  of  the  penis,  but  no 
definite  pain. 

Sexual  powers. — No  note  made. 

Examination. — Patient  is  a  sturdy  looking  man.  Chest  and  abdomen 
are  negative. 

Rectal. — Prostate  is  moderately  enlarged,  smooth,  elastic,  no  induration, 
no  nodules. 

Cystoscopy  was  not  performed.  There  was  considerable  residual  urine, 
but  no  note  has  been  made  as  to  the  amount. 

Operation,  June  9,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Two  fairly  enlarged  lateral  and  a  small  median  lobe  were 
easily  enucleated  without  removing  any  of  the  mucous  membrane  of  the 
urethra,  and  the  ejaculatory  duets  were  preserved  intact. 

The  patient  stood  the  operation  well.  The  wound  was  closed  as  usual 
with  double  drainage  tubes  and  light  packs  for  the  lateral  cavities.  The 
patient  stood  the  operation  well.  Infusion  and  continuous  irrigation  on 
return  to  room. 

Convalescence. — Continuous  irrigation  discontinued  after  14  hours.  The 
gauze  and  tubes  were  removed  on  the  second  day  and  soon  after  the 
urine  came  through  the  anterior  urethra.  The  patient  had  no  temperature 
above  99°,  was  up  on  the  second  day,  and  on  the  14th  day  could  retain 
urine  for  five  hours.  The  perineal  fistula  closed  completely  on  the  17th 
day,  and  the  patient  was  discharged  on  the  18th.  At  that  time  he  could 
retain  urine  five  hours.  Had  no  pain,  fistula  had  reopened  and  a  few 
drops  of  urine  had  escaped  through  it.  His  condition  was  excellent  and 
the  urine  apparently  normal.     The  fistula  finally  closed. 

November  30,  1905. — Letter.  The  wound  has  remained  closed,  I  void 
urine  naturally,  about  one-half  pint  at  a  time  about  four  or  five  times  dur- 
ing the  day  and  twice  at  night.     I  suffer  no  pain,  have  not  been  instru- 


364  Eugli  H.  Young. 

mented  since  operation  and  consider  myself  cured.  I  have  erections  and 
satisfactory  sexual  intercourse.  I  have  had  no  complications  and  my 
general  health  is  good. 

May  5,  1906. — Letter.  I  void  urine  naturally  at  fairly  normal  intervals, 
one-half  a  pint  at  a  time.  I  suffer  no  pain.  Sexual  intercourse  is  satis- 
factory. I  have  had  no  complications  or  treatment,  and  consider  myself 
cured. 

Pathological  report. — The  specimen,  G.  U.  264,  consists  of  three  pieces, 
two  lateral  lohes  and  a  small  median  lobe,  whole  weighing 
about  25  gr.  The  median  lobe  measures  only  1.5  x  1.3  x  .8  cm.  is  irregular 
and  on  section  looks  fibrous.  The  lateral  lobes  are  about  equal  in  size, 
measuring  about  3.5  x  3  x  2.5  cm.,  covered  by  fairly  smooth  capsule,  and  on 
section  show  numerous  spheroids.  A  number  of  dilated  acini  are  seen. 
The  consistence  is  uniformly  elastic.  No  mucous  membrane  or  ejaculatory 
ducts  have  been  removed. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  glandular 
one.  The  acini  are  for  the  most  part  only  moderately  dilated,  and  present 
a  rather  marked  papillomatous  proliferation.  The  stroma  is  rather  dense, 
almost  entirely  composed  of  fibrous  tissue.  There  is  present  considerable 
interstitial  and  periglandular  prostatitis. 

In  the  middle  lobe  the  prostatitis  is  more  intense,  and  almost  leads  to 
the  formation  of  abscesses  about  many  groups  of  acini.  The  arteries  show 
practically  no  thickening. 

Case  99. — Moderate  hypertrophy  of  lateral  and  median  loies.  Occasional 
catheterism.    Cured.    Followed  11  months. 

No.  1002.  C.  M.  M.,  age  56,  admitted  June  3,  1905,  at  St.  Francis  Hospital, 
La  Crosse,  Wisconsin. 

Complaint. — "  Frequent  and  painful  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  five  years  ago  with  pain  in  the  perineum  and 
difficulty  of  urination  which  lasted  only  a  few  days,  but  returned  six 
months  later  when  retention  became  complete  and  catheterization  neces- 
sary. During  the  next  three  years  he  had  to  be  catheterized  about  10 
times,  and  for  the  past  18  months  has  had  to  use  the  catheter  four  or  five 
times  every  month. 

S.  P. — Urine  is  voided  four  or  five  times  during  the  day  and  15  times 
at  night.  The  amount  passed  is  small,  and  there  is  a  severe  pain  in  the 
bladder  and  perineum  before  urination.    His  phj'sical  condition  is  good. 

Sexual  powers. — No  note  made. 

Examination. — The  patient  is  a  strong,  sturdj'  looking  man  with  lips 
of  good  color. 

Chest  and  abdomen  are  negative. 

Reclal. — The  prostate  is  considerably  enlarged,  smooth,  elastic,  no 
induration  in  the  region  of  the  seminal  vesicles.    Urine  of  good  quality. 

Operation,  June  9,  1905. — Ether.    Prostatectomy  by  the  usual  technique. 


study  of  145  Cases  of  Perineal  Prostatectomy.  365 

The  lateral  lobes  wMcli  were  considerably  enlarged  were  easily  enucleated. 
The  median  lobe  was  enucleated  through  one  of  the  lateral  cavities  without 
difficulty,  no  mucous  membrane  being  removed  and  only  a  small  tear 
being  made.  Search  of  the  bladder  failed  to  reveal  any  calculus.  Closure 
as  usual  with  double  tube  drainage  and  light  packs  for  the  lateral  cavities. 
Continuous  irrigation  and  infusion  on  return  to  room,  condition  of  patient 
excellent. 

Convalescence. — Patient  reacted  well.  The  irrigation  was  discontinued 
after  14  hours,  the  packing  was  removed  within  24  hours  and  the  drainage 
tubes  within  48  hours.  Immediately  afterwards  urine  was  voided  through 
the  urethra,  and  the  patient  was  gotten  out  of  bed.  On  the  fourth  day 
nearly  all  of  the  urine  came  through  the  anterior  urethra.  On  the  sixth 
day  the  patient  had  a  chill  and  temperature  of  105°,  but  after  that  the 
temperature  remained  normal.  The  patient  was  discharged  on  the  18th 
day.  His  condition  was  excellent,  urination  three  times  during  the  day  and 
twice  at  night,  without  pain  and  in  a  large  stream,  only  a  few  drops  of 
urine  escaped  through  the  perineal  fistula. 

July  11. — The  perineal  fistula  closed,  31st  day. 

December  S,  1905. — Letter  of  physician.  The  wound  has  remained  closed. 
Urine  is  voided  naturally,  about  one-half  pint  at  a  time  without  pain,  about 
five  times  during  the  day  and  five  times  at  night.  He  has  erections,  but 
has  not  attempted  intercourse.  He  has  recently  been  troubled  with  a 
nervous  disorder  of  the  stomach.  I  consider  him  entirely  cured  by  the 
operation. 

May  7,  1906. — Letter.  I  void  urine  naturally,  six  times  during  the  day 
and  twice  at  night,  about  four  ounces  at  a  time.  I  have  no  pain  except  a 
burning  sensation  when  I  urinate.  I  have  erections,  but  rarely,  have  not 
attempted  sexual  intercourse.  Eight  months  ago  I  had  pain  in  the  peri- 
neum and  fever  followed  by  a  discharge  of  pus  from  the  urethra  after  which 
I  slowly  got  better.  I  also  had  epididymitis  on  the  left  side.  My  general 
health  is  good,  and  I  have  gained  in  weight.  I  consider  myself  cured  apart 
from  what  I  have  described. 

September  11,  1906. — Letter.  The  perineal  fistula  closed  32  days  after 
the  operation.  I  void  urine  naturally,  six  or  seven  times  a  day  and  five 
times  at  night.  The  amount  voided  is  natural.  I  suffer  no  pain,  have 
erections  and  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  265,  consists  of  three  lobes 
of  the  prostate  removed  each  in  one  piece  and  weighs  about  G-20.  The 
lateral  and  median  portions  of  the  prostate  are  about  equal  in  size,  each 
being  about  3x2.5x2  cm.  They  are  smooth,  slightly  lobulated,  and  on 
section  show  considerable  gland  tissue,  but  also  a  good  amount  of  stroma. 
No  mucous  membrane,  no  ejaculatory  ducts,  no  calculi  removed. 

Microscopic  examination. — The  hypertrophy  is  a  moderately  glandular 
one  with  less  dilatation  of  the  acini  than  one  usually  sees,  but  the  off-shoots 
into  the  lumina  of  the  acini  from  the  lining  wall  are  present  in  considerable 
degree.  The  stroma  is  fairly  dense,  but  there  are  numerous  areas  where 
young  connective  tissue  has  been  formed.  Connective  tissue  is  in  excess 
of  the  muscle  elements.    The  blood  vessels  seem  practically  normal. 


366  Hugh  II.  Young. 

Case  100. — Large  hypertrophy  of  median  and  lateral  lobes.  Compli- 
cations:  Suppuration  in  wound.     Cholecystitis.     Cured. 

No.  965.     G.  W.  H.,  age  64,  married,  admitted  June  20,  1905. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  about  eight  years  ago  with  diflBculty  of  urination, 
pain  and  incontinence  which  continued  for  several  weeks.  One  year  later 
he  had  retention  of  urine  for  the  first  time,  and  after  that  with  increasing 
frequency  until  three  years  ago  when  the  retention  became  complete  and 
chronic  and  he  has  led  a  catheter  life.  Two  years  ago  he  had  epididymitis 
on  the  left  side.  He  has  had  a  dull  aching  pain  in  the  bladder,  but  none 
elsewhere.    No  hematuria,  no  calculus. 

S.  P. — The  catheter  is  used  at  bed  time  and  he  voids  first  at  4  a.  m. 
He  uses  the  catheter  again  in  the  morning  and  does  not  void  then  for  four 
hours,  after  which  he  voids  every  two  hours.  Catheterization  is  often 
very  difficult  and  sometimes  produces  hemorrhage.  His  general  health  is 
good. 

Sexual  powers. — Erections  and  coitus  satisfactory. 

Examination. — The  patient  is  a  well  nourished,  healthy  looking  man. 
Chest  and  abdomen  negative. 

Rectal. — Prostate  is  considerably  enlarged,  smooth,  soft,  no  nodules  or 
induration,  the  upper  end  can  be  passed  with  difficulty.  The  seminal 
vesicles  are  negative. 

Cystoscopic. — A  catheter  passes  with  ease  and  finds  360  cc.  residual 
urine.  The  bladder  capacity  is  large.  The  cystoscope  shows  a  fairly  large 
median  lobe  and  considerable  intravesical  enlargement  of  the  lateral  lobes. 
The  bladder  is  trabeculated,  cystitis  moderate,  no  calculus.  With  cysto- 
scope in  urethra  and  finger  in  rectum,  the  median  portion  appeared  quite 
thick  and  the  beak  could  not  be  felt  owing  to  the  length  of  the  prostate. 

Urinalysis. — Cloudy,  1022,  acid,  no  sugar,  no  albumin,  pus  cells  and 
bacteria. 

Operation,  June  21,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Both  lateral  lobes  were  quite  large.  While  enucleating  the 
left  lateral  lobe  it  was  found  possible  by  directing  one  blade  of  the 
tractor  so  as  to  engage  the  summit  of  the  middle  lobe  to  draw  it  down  and 
enucleate  it  in  one  piece  with  the  left  lateral.  A  median  bar  was  left 
and  this  was  removed  in  two  pieces  also  through  the  left  lateral  cavity. 
A  tear  was  made  in  the  mucous  membrane  of  the  median  portion,  but 
none  removed.  The  ejaculatory  ducts  were  apparently  preserved.  Usual 
closure  with  double  drainage  tubes  and  light  packs  for  the  lateral  cavities. 

The  patient  stood  the  operation  well,  infusion,  pulse  at  the  end  70. 
Continuous  irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well,  and  had  a  practically  normal 
temperature  and  for  three  weeks  the  temperature  was  normal  except  on 
the  fifth  day  when  it  reached  to  100.5°.  The  tubes  and  gauze  were  removed 
on  the  third  day,  and  interval  urination  was  established  almost  at  once. 
Urine    did    not    flow    through   the   anterior    urethra    until    the    13th    day. 


study  of  lJj.5  Cases  of  Perineal  Prostatectomy.  367 

The  sutured  wound  did  not  heal  per  primam  and  left  a  large  wound  to 
granulate.  On  the  25th  day  there  was  a  sudden  rise  of  temperature  to 
102.9  at  6  p.  m.  and  examination  showed  a  distended  tender  gall  bladder. 
This  attack  persisted  for  two  'weeks  during  which  the  patient  was  con- 
fined to  bed..  The  perineal  fistula  healed  completely  on  the  40th  day  and 
he  left  the  hospital  on  the  44th  day  in  good  condition,  voiding  urine  in  a 
free  stream  at  intervals  of  three  hours  or  more. 

November  30,  1905. — Letter.  The  wound  has  remained  closed.  I  have 
had  no  instrumentation.  I  void  urine  at  normal  intervals,  about  three- 
quarters  of  a  pint  at  a  time.  Have  no  pain  and  am  perfectly  cured.  I 
have  had  several  erections,  but  have  practically  no  sexual  desire. 

May  8,  1906. — Letter.  I  am  perfectly  cured,  there  is  no  fistula,  I  do  not 
use  a  catheter.  I  have  nb  pain.  Have  not  had  erections  or  intercourse. 
My  general  health  is  excellent.    I  have  gained  25  pounds. 

Pathological  report.- — The  specimen,  G.  U.  173,  consists  of  the  prostate 
removed  in  three  pieces,  weighing  about  G-60.  The  left  lobe  is  the  larger, 
weighs  G-30  and  measures  5x4x3  cm.  It  is  irregular,  lobulated  and  on 
section  shows  many  spheroids,  considerable  dilatation  of  the  ducts  and 
also  considerable  stroma.  The  right  lobe  weighs  G-22,  and  measures 
5x3x4  cm.  It  is  more  regular  than  the  left  and  is  similar  in  appearance. 
The  median  lobe  weighs  G-8,  and  is  about  2.5  cm.  in  diameter,  is  consider- 
ably torn.  No  mucous  membrane  is  attached,  no  ejaculatory  ducts,  no 
calculi. 

Microscopic  examination.— iThe  sections  show  a  tissue  which  is 
largely  arranged  in  lobules.  Within  these  lobules  the  acini  are 
very  much  dilated  and  the  epithelium  for  the  most  part  is 
flattened.  There  is  some  intracystic  outgrowth  in  many  of  the  di- 
lated acini,  but  most  of  them  are  smooth  walled,  and  show  very  little 
of  the  complexity  of  the  wall  which  is  present  in  many  of  the  small  acini. 
The  stroma  in  places  is  quite  dense,  and  in  other  places  slender  bands  only 
are  present  between  the  acini.  There  is  a  very  marked  inflammation 
throughout  the  greatest  part,  and  there  are  some  areas  in  the  denser 
stroma  where  the  ducts  are  compressed,  and  chronic  inflammatory  tissue 
has  been  formed  in  quite  thick  bands  about  these  acini.  The  amount  of 
muscle  varies  in  different  portions,  in  some  places  being  fairly  abundant, 
while  in  others  the  connective  tissue  predominates. 

The  tissue  is  that  of  a  fibro-myoadenoma  in  which  the  adenomatous 
tissue  is  very  abundant  especially  in  the  lobulated  areas,  and  has  under- 
gone quite  a  marked  cystic  degeneration.  There  is  a  very  marked  in- 
flammatory change  present  with  the  formation  of  considerable  perigland- 
ular and  interstitial  inflammatory  tissue.  Some  corpora  amylacea  are 
seen. 

Case  101. — ^Moderate  enlargement  of  median  and  lateral  lobes.     Calculus 
in  bladder.    Seed  calculi  in  prostate.    Cured.    Followed  11  months. 
No.  954.     R.  W.  M.,  age  65,  married,  admitted  June  8,  1905. 
Complaint. — "  Enlarged  prostate  and  stricture." 
Patient  had  gonorrhcea  30  years  ago. 


368  Hugh  H.  Young. 

Present  illness. — The  patient  has  had  some  urinary  difficulty  for  20 
years,  beginning  with  a  burning  in  the  deep  urethra  and  frequency  of  uri- 
nation. This  condition  persisted  for  about  10  years  when  he  was  examined 
by  a  physician  who  told  him  that  he  had  two  strictures  and  passed  instru- 
ments. This  did  not  cure  him  of  his  trouble  which  has  persisted  up  to 
the  present  time. 

S.  P. — His  condition  is  now  about  the  same  as  10  years  ago.  He  voids 
urine  every  two  hours  night  and  day,  and  suffers  burning  pain  in  the  neck 
of  the  bladder  during  and  after  urination. 

Sexual  poxcers. — Occasionally  has  normal  erections..  Has  had  no  inter- 
course for  two  years. 

Examination. — ^The  patient  is  well  nourished.  Has  not  lost  weight. 
Heart,  lungs,  and  abdomen  are  negative. 

Rectal. — The  prostate  is  only  slightly  enlarged,  symmetrical,  distinctly 
harder  than  normal,  but  not  of  stony  hardness.  Smooth  with  no  nodules. 
The  right  seminal  vesicle  is  distinctly  palpable  and  slightly  indurated,  but 
the  left  vesical  is  not  indurated.  The  prostate  does  not  extend  up  into  the 
region  of  either  vesicle,  and  there  is  no  intravesicular  mass. 

Oystoscopic. — A  catheter  passes  with  ease  and  finds  450  cc.  residual 
urine  (yesterday  it  was  200  cc).  The  cystoscope  shows  a  slight  intravesi- 
cal enlargement  all  around  the  orifice  in  the  shape  of  a  collarette  with 
no  intervening  sulci.  The  bladder  is  considerably  inflamed,  markedly 
trabeculated  with  several  small  and  one  large  diverticula.  On  the  trigone 
rests  a  large  oval,  freely  movable  calculus.  With  finger  in  rectum  and 
cystoscope  in  urethra  the  prostate  feels  like  a  hard  collar  around  the 
shaft,  and  the  beak  is  easily  felt. 

Urinalysis. — Cloudy,  alkaline,  sp.  gr.  1010,  albumin  a  trace,  no  sugar. 
Microscopically,  a  few  pus  cells,  bacilli  and  cocci. 

Operation.  June  21,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  rectum  was  found  very  adherent  to  membranous  urethra 
and  apex  of  the  prostate,  and  in  freeing  it  a  small  tear  was  made  into  the 
rectum.  It  was  not,  however,  until  the  completion  of  the  prostatectomy. 
The  bilateral  capsular  incision  exposed  at  once  multiple  seed  calculi  in  the 
prostatic  substance  on  each  side.  These  varied  from  1  to  4  mm.  in  size. 
The  lateral  lobes  were  only  slightly  enlarged,  and  owing  to  adhesions  were 
removed  with  difficulty.  The  urethra  was  then  divided  along  the  left  lateral 
wall,  the  neck  of  the  bladder  dilated,  stone  forceps  introduced  and  a  fairly 
large  oval  calculus  removed.  Examination  showed  no  further  calculi.  A 
finger  in  the  urethra  then  showed  a  slight  median  enlargement  which  was 
excised.  Double  catheter  drains  were  placed  in  the  urethra  which  was  not 
closed  by  sutures.  The  lateral  cavities  were  packed  with  gauze.  Glove 
finger  was  then  inserted  in  the  rectum  and  palpation  with  the  finger  of 
the  other  hand  in  the  wound  showed  a  tear  in  the  anterior  part  of  the  rec- 
tum. This  was  closed  by  interrupted  sutures  of  fine  silk,  two  rows  which 
were  in  turn  covered  in  by  a  row  of  catgut  sutures.  The  levator  muscles 
were  then  approximated  and  the  cutaneous  wound  partially  closed  on  each 
side  as  usual.  The  patient  stood  the  operation  well,  the  pulse  at  the  end 
being  95.     Infusion  and  continuous  irrigation  on  return  to  ward. 


study  of  IJj-o  Cases  of  Perineal  Prostatectomy.  369 

Convalescence. — The  temperature  arose  to  101  en  the  day  after  the  op- 
eration, but  after  that  remained  100  for  a  week  before  returning  to  normal. 
On  account  of  the  wound  in  the  rectum  the  bowels  were  not  opened  for  six 
days,  during  which  time  the  diet  was  very  limited  and  a  lead  and  opium 
pill  was  administered.  Caster  oil  by  mouth  and  an  oil  enema  were  used  to 
move  bowels.  The  irrigation  was  discontinued  after  24  hours,  the  gauze 
and  tubes  were  removed  after  36  hours.  He  had  a  slight  epididymitis  five 
days  after  the  operation,  but  after  a  few  days  the  swelling  and  pain  dis- 
appeared. The  rectal  wound  healed  per  primam.  He  was  discharged  from 
the  hospital  on  the  25th  day.  At  that  time  he  was  able  to  retain  urine  for 
six  or  seven  hours,  voided  in  a  large  stream  without  pain,  difficulty  or 
incontinence.  His  condition  was  excellent.  A  pin  point  fistula  was  pres- 
ent which  was  curetted.  A  silver  catheter  passed  with  ease,  meeting  no 
obstruction  and  finding  no  residual.  The  urine  contains  pus  cells  and 
bacilli.    The  fistula  finally  closed  on  the  27th  day. 

July  20,  1905. — 'The  wound  is  healed.  The  patient  arose  once  last  night 
to  urinate,  has  perfect  control.    Has  already  had  several  partial  erections. 

February  19,  1906. — -I  void  urine  naturally  twice  at  night,  and  sometimes 
a  pint  at  a  time.  There  is  no  fistula  present,  but  the  wound  is  a  little 
sore.  I  do  not  have  erections.  My  general  health  is  good,  and  I  have 
gained  in  weight. 

May  23,  1906. — Letter.  I  void  urine  naturally  and  at  fairly  normal  in- 
tervals, and  from  one-half  to  one  pint  at  a  time.  I  do  not  suffer  much 
pain.  I  do  not  have  erections.  My  general  health  is  quite  good.  The 
wound  has  remained  closed  and  I  am  very  much  improved  by  the  opera- 
tion. 

Pathological  report. — >The  specimen,  G.  U.  172,  consists  of  two  small 
pieces  of  prostatic  tissue  and  weighs  less  than  10  gm.  The  left  lobe  meas- 
ures 3  X  1.5  x  1  cm.  and  the  right  lobe  2.5  x  2  x  .8  cm.  The  external  surfaces 
are  rough,  irregular,  torn.  On  section  there  is  considerable  fibrous  stroma, 
a  moderate  amount  of  gland  tissue,  and  no  dilatation  of  the  ducts,  no  mu- 
cous membrane,  no  ejaculatory  ducts  present.  An  oval  calculus  3.5  x  2.5  x  2 
cm.  has  been  removed,  is  yellowish  in  color  and  finely  granular. 

Microscopic  examination. — The  section  shows  the  tissue  mostly 
composed  of  stroma.  There  are  some  areas  in  which  the  gland 
tissue  is  grouped  together  in  fair  amounts.  The  glands  are  for 
the  most  part  rather  small,  and  everywhere  is  present  quite  a 
marked  prostatitis.  About  the  individual  acini,  and  those  grouped  in 
lobules,  there  is  a  very  marked  periglandular  infiltration  of  round  cells 
and  polynuclears.  The  infiltration  often  extends  out  into  the  interstitial 
tissue  for  a  considerable  distance,  but  is  distinctly  much  more  pronounced 
immediately  about  the  acini.  About  some  of  the  glands  there  has  been 
formed  apparently  considerable  amounts  of  inflammatory  tissue.  The  epi- 
thelium lining  some  of  the  ducts  is,  in  places,  thickened,  and  in  other  parts 
desquamated.  Numerous  polynuclears  are  present  in  many  of  the  acini. 
The  stroma  as  a  whole  is  rather  dense;  is  composed  in  large  part  of  fibrous 
tissue,  although  considerable  smooth  muscle  tissue  is  present.  The  pic- 
ture is  almost  purely  one  of  chronic  prostatitis. 


370  Hugh  H.  Young. 

Case  102. — 'Slight  enlargement  of  median  and  lateral  lobes.  Consider- 
able pain.    Cured.    Followed  11  months. 

No.  950.     C.  M.  H.,  age  52,  married,  admitted  May  25,  1905. 

Complaint. — ■"  Enlarged  prostate." 

No  tiistory  of  gonorrhcea. 

Present  illness  began  seven  years  ago  with  slight  burning  in  the  urethra 
and  frequent  urination.  The  condition  gradually  grew  worse  and  nine 
months  ago  the  patient  was  voiding  urine  every  hour,  night  and  day,  and 
there  was  severe  burning  sensation  in  the  urethra.  Five  months  ago  urina- 
tion occurred  about  every  15  minutes,  and  he  was  catheterized  by  a  physi- 
cian and  15  ounces  of  urine  was  withdrawn,  after  that  the  catheter  was 
passed  several  times  and  his  condition  improved  considerably,  but  he  suf- 
fered so  much  pain  in  the  urethra  that  he  began  the  use  of  morphine  which 
he  has  not  used  for  some  time.  The  patient  urinates  about  every  two  and 
one-half  hours  night  and  day.  There  is  no  hesitation  and  the  stream  is 
large,  but  there  is  considerable  burning  and  straining  at  the  end  of  urina- 
tion. He  has  never  had  hematuria  or  passed  a  stone.  His  sexual  powers 
are  impaired.  He  has  not  had  intercourse  for  six  months,  but  he  still  has 
erections. 

Eo:ar,iination.~^Th.e  patient  is  thin,  emaciated.  Mucous  membranes  are 
pale.  Lungs  are  negative.  The  heart  is  enlarged  and  a  soft,  systolic  mur- 
mur is  present  at  the  ape'x  and  in  the  tricuspid  area.  The  abdomen  is 
negative.  Inguinal  glands  are  not  enlarged.  Examination  of  the  blood 
shows  76%  hemoglobin,  reds  3,550,000. 

Rectal  examination. — The  prostate  is  moderately  enlarged  in  both  lat- 
eral lobes,  the  left  being  the  larger.  It  is  rounded,  smooth,  soft,  and  not 
tender.  The  right  seminal  vesicle  is  slightly  indurated,  but  the  left  is 
soft.     No  enlarged  glands  are  to  be  felt. 

June  12,  1905. — 'The  patient  returns  for  operation.  He  has  considerable 
pain  in  voiding  and  urinates  about  every  15  minutes  with  marked  strain- 
ing.   A  catheter  is  passed  and  180  cc.  cloudy  urine  is  withdrawn. 

Urinalysis. — Cloudy,  acid.  Sp.  gr.  1025,  albumin  a  trace.  Microscopic- 
ally, pus  cells.  He  is  put  on  urotropin,  30  grains  a  day,  and  instructed  to 
return  for  catheterization  once  daily. 

June  17. — 'The  patient  has  improved,  but  he  has  been  taking  morphine  in 
considerable  quantity.  He  suffers  greatly  from  pain  in  urethra  and 
bladder. 

Cystoscopic  examination. — *A  catheter  passes  with  ease  and  withdraws 
250  cc.  residual  urine.  The  bladder  is  very  irritable  and  it  is  impossible 
to  get  its  correct  capacity.  Cystoscope  showed  two  fairly  large  lateral 
lobes  with  a  deep  sulcus  in  front  and  a  shallow  sulcus  behind  and  a  small 
median  bar  connecting  the  two.  Both  ureters  were  visible  and  normal  in 
appearance.  The  bladder  is  slightly  trabeculated  and  acutely  inflamed. 
With  the  finger  in  the  rectum  and  cystoscope  iu  the  urethra  the  beak  can 
be  felt,  the  trigone  is  soft,  and  there  is  very  little  increase  in  the  median 
portion  of  the  prostate.  The  urine  contains  pus  cells  and  bacilli  in  large 
numbers. 


study  of  lJf-5  Cases  of  Perineal  Prostatectomy.  371 

Note. — IFollowing  cystoscopy  the  patient  had  a  rise  of  temperature  to 
104°.  There  was  no  evidence  of  pneumonia  nor  renal  infection,  but  five 
days  later  he  still  had  a  temperature  of  103°,  and  it  was  thought  probable 
that  the  fever  was  due  to  absorption  from  the  bladder  and  operation  was 
therefore  performed  at  once. 

Operation,  June  21,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  moderately  enlarged,  soft  and  easily 
enucleable.  The  median  portion,  which  was  very  small,  was  removed 
through  the  left  lateral  cavity,  a  small  tear  being  made  in  the  urethra. 
The  rest  of  the  urethra  and  ejaculatory  ducts  were  preserved  intact.  The 
wound  was  closed  with  double  drainage  tubes  for  the  bladder  and  the  late- 
ral cavities  packed  lightly  with  gauze.  Continuous  irrigation  was  begun 
at  the  operating  table,  infusion  on  return  to  the  ward.  His  pulse  re- 
mained high  throughout  the  operation,  being  135  at  the  end,  but  his  condi- 
tion was  otherwise  good. 

Convalescence. — Condition  of  the  patient  improved  rapidly  after  the  op- 
eration. The  temperature  fell  to  normal  the  next  morning  and  remained 
so  after  the  third  day  for  ten  days.  The  gauze  and  catheters  were  re- 
moved on  the  second  day.  The  patient  suffered  considerable  from  vesical 
and  urethral  irritability  and  the  urine  did  not  begin  to  iiow  through  the 
urethra  until  the  15th  day,  but  the  fistula  closed  completely  on  the  25th 
day.  On  the  tenth  day  epididymitis  developed  on  the  left  side,  and  about 
two  weeks  later  upon  the  right  side.  During  this  time  the  temperature 
which  had  been  normal  arose  and  for  two  weeks  varied  from  100°  to 
102.5°,  when  it  again  became  normal.  A  week  later,  however,  the  fever 
returned  and  he  continued  to  have  a  daily  temperature  of  103°  for  several 
days.  The  patient  was  a  very  weak  subject  and  convalesced  poorly.  He 
complained  severely  of  the  need  of  morphine.  After  August  3  he  was  free 
from  fever,  but  did  not  leave  the  hospital  until  August  13,  when  he  was 
discharged,  49  days  after  the  operation.  At  that  time  he  was  able  to  main- 
tain his  urine  from  four  to  five  hours,  stream  was  large,  a  catheter  passed 
with  ease  and  found  no  residual  urine.  At  times,  when  moving  around, 
a  few  drops  of  urine  escaped,  but  as  a  rule  he  had  perfect  control.  Both 
epididymes  were  indurated,  but  neither  had  gone  on  to  suppuration.  His 
general  condition  was  much  improved. 

November  30,  1905. — Letter.  The  perineal  wound  is  closed.  I  void  urine 
naturally,  once  or  twice  at  night,  four  or  five  times  during  the  day,  often 
as  much  as  a  pint  at  a  time,  and  I  consider  myself  cured.  Erections  have 
returned  and  sexual  intercourse  is  entirely  satisfactory.  I  have  gained  35 
pounds  in  weight,  and  my  health  is  excellent. 

May  9,  1906. — (Letter.  I  void  urine  naturally  three  or  four  times  a  day 
and  once  at  night,  from  12  to  16  ounces  at  a  time.  I  suffer  no  pain.  Erec- 
tions and  intercourse  are  entirely  satisfactory.  My  general  health  has 
never  been  better.     I  have  gained  in  weight,  and  I  consider  myself  cured. 

September  15,  1906. — Letter.  I  void  urine  naturally  three  or  four  times 
during  the  day  and  once  at  night,  about  10  or  12  ounces  at  a  time.  Sexual 
intercourse  is  normal  and  entirely  satisfactory.     I  am  entirely  cured. 


372  Hugli  H.  Young. 

Pathological  report. — ^The  specimen,  G.  U.  171,  consists  of  three  pieces 
of  prostatic  tissue  comprising  the  three  lobes.  The  total  weight  is  about 
18  grams.  The  left  lobe  is  a  lobulated  mass,  typical  of  benign  hypertrophy 
and  weighs  about  nine  grams.  The  right  lobe  is  composed  of  a  number 
of  spheroids,  elastic  in  consistency,  and  weighs  about  seven  grams.  The 
middle  lobe  is  a  small,  irregular  mass,  weighing  two  grams,  is  much  more 
fibrous  than  either  of  the  lateral  lobes,  but  a  few  small  spheroids  are  pres- 
ent.   The  ejacuatory  ducts  have  not  been  removed.    No  calculus  present. 

Microscopical  examination. — The  tissue  of  the  lateral  lobes  contains  very 
little  gland  tissue,  while  in  the  section  from  the  middle  lobe  there  is 
scarcely  any  gland  tissue  at  all.  In  the  lateral  lobes  one  finds  small  areas 
where  there  is  some  gland  tissue  grouped  together  in  lobules,  but  the 
acini  are  not  dilated.  The  epithelium  is  cylindrical  in  type,  in  places  one 
layer  thick,  in  other  ducts  part  of  the  wall  has  an  epithelium  many  layers 
thick.  Throughout  the  greater  part,  the  gland  tissue  is  atrophied  and  the 
ducts  are  compressed,  the  epithelium  in  many  instances  being  entirely 
absent.  Everywhere  throughout  the  section  there  is  marked  round  cell  in- 
filtration with  extensive  formation  of  inflammatory  tissue.  In  areas  there 
is  a  fair  amount  of  muscle  tissue  present,  but  in  the  majority  of  the  areas 
the  fibrous  tissue  is  distinctly  more  abundant.  The  middle  lobe  contains 
practically  no  gland  tissue,  and  the  ducts,  which  are  present,  are  for  the 
most  part  compressed  and  atrophied.  Everywhere  very  extensive  round 
cell  infiltration  with  formation  of  new  connective  tissue  is  present. 

This  is  a  distinctly  fibrous  type  of  hypertrophy,  the  gland  and  myoma- 
tous tissue  being  comparatively  small  in  amount. 

Case  103. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Catheter 
three  months.    Cured. 

No.  969.    J.  S.  A.,  age  61,  married,  admitted  June  22,  1905. 

Complaint. — "  Prostatic  obstruction.     Catheterism." 

No  history  of  gonorrhcea. 

Present  illness  began  seven  years  ago  with  frequency,  difficult  urina- 
tion and  slight  pain. 

Course  of  disease. — 'Gradual  increase  in  frequency  and  difficulty  until 
March,  1905,  when  he  was  urinating  every  two  hours  and  suffered  consid- 
erable pain  at  end  of  penis.  Had  no  complete  retention  of  urine.  Began 
the  use  of  a  catheter  three  months  ago.  Since  then  has  used  it  twice 
daily,  has  been  free  from  pain,  has  never  had  hematuria,  has  lost  no 
weight. 

S.  P. — (He  catheterizes  himself  at  bedtime,  and  withdraws  about  five 
ounces  of  residual  urine.  Does  not  rise  to  urinate  until  7  a.  m.  Uses  the 
catheter  again  at  10  a.  m.,  and  voids  again  at  5  p.  m.  and  again  about  8 
p.  m.,  passing  five  or  six  ounces  each  time.  Suffers  no  pain,  but  finds  the 
catheter  an  "  infernal  nuisance." 

Sexual  powers. — 'Considerably  weakened,  but  is  still  able  to  have  inter- 
course.   Erections  infrequent,  but  fairlj'  good.    General  health  excellent. 

Examination. — ^Patient  is  a  sturdy  looking  man.  Chest  and  abdomen 
negative. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  373 

Genitalia. — ^The  corona  of  the  glans  penis  is  congenitally  obliterated, 
owing  to  adhesion  of  prepuce  to  anterior  portion  and  glans  at  a  point  1  cm. 
distant. 

Rectal. — <The  prostate  is  moderately  hypertrophied,  the  left  lobe  being 
the  larger.  It  is  smooth,  soft,  not  tender  and  contains  no  nodules.  Semi- 
nal vesicles  are  soft.  The  vasa  deferentia  are  apparently  indurated  and 
enlarged,  and  a  prominent  septum-like  band  of  fibrous  tissue  extends  from 
the  upper  end  of  the  left  lateral  lobe  out  to  join  the  pelvis.  No  enlarged 
glands  are  felt. 

Urinalysis. — Cloudy,  acid,  1022,  no  albumin,  no  sugar..  Microscopically, 
pus  cells  and  bacteria. 

Cystoscopic. — >Small  silk  catheter  passes  with  ease,  finding  340  cc.  re- 
sidual urine.  Bladder  capacity  is  large  and  tonicity  is  good.  The  cysto- 
scope  shows  very  little  enlargement  of  the  lateral  lobes,  but  no  cleft  be- 
tween them  anteriorly.  The  median  portion  of  the  prostate  is  slightly 
enlarged  with  a  shallow  sulcus  between  it  and  the  lateral  lobes  on  each 
side.  In  front  of  the  median  lobe,  the  lateral  lobes  are  seen  to  come  to- 
gether and  compress  the  prostatic  urethra,  both  ureters  are  easily  seen, 
and  are  apparently  normal.  The  bladder  is  trabeculated  with  numerous 
shallow  pouches.  There  is  slight  cystitis,  no  foreign  bodies.  With  finger 
in  rectum  and  cystoscope  in  urethra  the  beak  is  easily  felt,  and  the  thick- 
ness in  the  median  portion  is  only  slightly  increased. 

Operation,  June  2If,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  moderately  enlarged,  measuring  each 
about  3x4x5  cm.  The  median  portion  of  the  prostate  was  removed 
through  one  of  the  lateral  cavities  and  measured  2  x  2%  x  3  cm.  A  small 
tear  was  made  in  the  urethra,  but  the  ejaculatory  ducts  were  preserved. 
The  rectum  was  very  adherent  to  the  posterior  capsule  of  the  prostate, 
and  a  small  tear  was  made  into  it  with  the  finger.  After  completion  of  the 
operation  the  hole  was  closed  with  several  layers  of  fine  silk  sutures.  The 
levator  muscles  were  drawn  together  with  catgut.  The  rest  of  the  wound 
was  closed  as  usual  with  double  catheter  drainage  and  light  packs  for  the 
lateral  cavities.  Patient  stood  the  operation  well,  pulse  at  the  end  75.  In- 
fusion and  continuous  irrigation  on  return  to  the  ward. 

Convalescence. — ^Patient  reacted  well,  and  during  the  first  six  days  the 
highest  temperature  was  100.5°.  The  irrigation  was  discontinued  after  12 
hours,  the  gauze  was  removed  in  24  hours  and  the  tubes  in  48  hours.  The 
urine  came  through  the  anterior  urethra  on  the  fourth  day,  and  he  was 
able  to  retain  it  for  two  or  three  hours.  The  patient  was  kept  on  milk 
diet  and  the  bowels  were  not  moved  until  seventh  day  with  calomel.  The 
rectal  sutures  did  not  break  down.  Epididymitis  set  in  on  the  ninth  day, 
and  was  accompanied  by  a  temperature  of  104°,  which  rapidly  fell  to  nor- 
mal. After  eight  days  the  epididymitis  had  completely  disappeared  under 
treatment  with  ice.  The  perineal  fistula  closed  on  the  19th  day,  and  the 
patient  was  ready  to  go  home,  but  on  July  14  he  had  a  slight  fever  and 
phlebitis  came  on  on  the  left  side.  For  five  days  the  jpatient  had  a  tem- 
perature which  reached  101°  to  102°,  after  that  it  remained  practically 


374  Hugh  H.  Young. 

normal,  but  his  leg  was  tender  and  he  was  not  discharged  from  the  hospital 
until  the  34th  day.  At  that  time  his  condition  was  excellent,  he  voided 
urine  freely,  at  intervals  of  three  hours,  the  wound  was  closed,  a  cath- 
eter showed  55  cc.  residual  urine,  and  no  stricture.  The  rectal  and  peri- 
neal wounds  were  tightly  closed. 

December  30,  1905. — ^Letter.  I  void  urine  once  during  the  night  and 
four  times  during  the  day,  about  10  ounces  at  a  time,  suffer  no  pain.  The 
wound  is  closed,  I  have  not  been  instrumented  and  I  consider  myself 
cured.  I  have  had  no  erections,  but  before  operation  intercourse  was  very 
unsatisfactory.    My  general  health  is  excellent. 

May  7,  1906. — ^Letter.  The  wound  has  remained  healed.  I  void  urine 
naturally,  only  once  during  the  night,  and  as  much  as  15  ounces  at  a  time. 
I  have  a  slight  pain  at  the  end  of  urination  and  have  not  had  erections. 
My  general  health  is  excellent,  and  I  consider  myself  cured. 

September  14,  1906. — Letter.  Urination  is  normal,  three  or  four  times 
during  the  day,  often  not  at  all  during  the  night,  12  ounces  or  more  in 
amount.     I  have  erections,  but  my  sexual  capacity  is  weak.     I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  175,  consists  of  the  median, 
right  and  left  lobes  removed  in  four  pieces,  the  whole  forming  a  small 
mass  which  weighs  not  more  than  15  gm.  The  lateral  lobes  are  about 
equal  in  size  and  measure  3x2.5x2  cm.  The  median  bar  measures  2x1 
X  1  cm.  The  surfaces  of  the  lateral  lobes  are  smooth,  soft,  and  on  section 
show  the  typical  picture  of  adenomatous  hypertrophy.  Fibrous  tissue  is 
more  abundant  in  the  right  than  in  the  left.  The  median  bar  shows 
glandular  tissue  with  considerable  fibrous  stroma. 

Microscopic  examination. — The  tissue  contains  more  stroma  than  gland- 
ular elements.  The  acini  occur  oftentimes  in  small  aggregations,  and 
there  seems  only  a  small  tendency  to  formation  of  lobules.  The  stroma 
is  composed  mostly  of  fibrous  tissue,  the  muscular  fibers  being  compara- 
tively few  in  number.  There  is  a  tendency  in  this  hypertrophy  towards 
the  fibrous  type.  There  are  very  numerous  corpora  amylacea  in  the  culs- 
de-sac. 

Case  104. — Anterior  lobe,  growing  out  from  right  lateral.  Small  median. 
Three  calculi.    Cure. 

No.  969.     E.  G.  C,  age  55,  married,  admitted  June  22,  1905. 

Complaint. — "  Enlarged  prostate." 

Gonorrhoea  at  the  age  of  20,  mild  attack  without  complication. 

Present  illness  began  six  years  ago  with  difficulty  of  urination.  The 
course  of  the  disease  was  gradual  up  to  January,  1904,  when  complete 
retention  of  urine  came  on.  He  was  then  catheterized  for  two  weeks. 
Since  then  has  not  used  a  catheter  except  when  urination  was  unusually 
difficult. 

S.  P. — At  present  voids  urine  three  times  during  the  night,  15  times 
during  the  day.  Urination  painful,  but  never  radiates  to  end  of  penis, 
but  sometimes  to  back.  No  hematuria.  Micturition  is  slow  and  difficult. 
One  month  ago  the  residual  was  10  ounces. 

Sexual  powers. — Good.     General  health  excellent. 


study  of  IJfO  Cases  of  Perineal  Prostatectomy. 


375 


Examination. — A  well  nourished  man,  lips  of  good  color,  no  arterio- 
sclerosis.    Chest  and  abdomen  negative. 

Rectal. — Prostate  is  slightly  enlarged,  the  posterior  surface  being  flat, 
outlines  difficult  to  make  out.  It  is  soft,  smooth,  not  tender,  and  there 
are  no  nodules,  seminal  vesicles  are  negative..  The  prostatic  secretion 
contains  numerous  lecithins,  moderate  number  of  granule  cells  and  a  few 
pus  cells,  actively  motile  spermatozoa. 

Urinalysis. — Cloudy,  alkaline,  sp.  gr.  1022,  albumin  a  slight  trace,  mi- 
croscopically, pus  cells  and  staphylococci. 

Cystoscopic. — A  coude  catheter  passes  with  ease.  Residual  urine  100  cc. 
bladder  capacity  250  cc.  The  cystoscope  shows  a  small  rounded  median 
lobe,  very  little  enlargement  of  the  left  lateral  lobe,  considerable  intra- 
vesical enlargement  of  the  right  lateral  lobe  which  presents  upward  so 


Fig.  48.— Case  104. 


that  it  is  seen  in  front  of  the  urethral  orifice  as  a  prominent  overhanging 
mass,  as  seen  in  the  accompanying  cystoscopic  pictures.  Fig.  48.  In  the 
series  A.  L.  with  the  cystoscope  looking  upward  and  to  the  left,  the  side  of 
this  anterior  lobe  is  seen,  and  the  sulcus  is  shown  to  become  deeper  as  the 
handle  of  the  cystoscope  is  elevated  in  No.  2  and  3.  In  Fig.  X.  the  apex 
of  this  anteriorly  projecting  lobe  is  seen.  This  condition  is  an  unusual 
finding.  In  R.  the  deep  sulcus  between  the  middle  lobe  and  right  lateral 
lobe  is  seen.  The  bladder  is  slightly  trabeculated  and  contains  two  calculi, 
one  smaller  than  the  other.  "With  finger  in  rectum  and  cystoscope  in 
urethra  the  median  enlargement  appeared  only  moderate. 

Operation,  June  24,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Removal  of  three  calculi  through  the  wound  after  division 
of  lateral  wall  of  the  urethra  and  dilatation  of  the  neck  of  the  bladder. 
The  larger  stone  measured  3  x  2^^  x  2  cm.,  the  others  were  much  smaller. 
The  lateral  lobes  were  only  slightly  enlarged.  The  median  lobe  was  small 
and   removed   through   one    of   the   lateral    cavities.     The    operator    had 


376  Hugh  H.  Young. 

forgotten  the  cystoscopic  findings  and  thought  the  operation  was  complete, 
after  removal  of  the  calculi  the  finger  was  inserted  in  the  bladder  and 
showed  at  once  a  prominent  overhanging  anterior  lobe,  which  had  been 
seen  with  the  cystoscope.  It  was  easily  drawn  into  the  right  lateral 
cavity,  and  enucleated.  It  was  about  2  cm.  in  diameter.  The  wound 
was  closed  as  usual  with  double  tube  drainage  and  slight  packs  for  the 
lateral  cavities.  Pulse  at  the  end  of  the  operation  was  76.  Infusion 
and  continuous  irrigation  on  return  to  the  ward. 

Convalescence. — For  four  days  the  patient  had  temperature  varying 
between  99°  and  100.7°,  after  that  practically  normal.  The  irrigation 
was  discontinued  after  12  hours,  and  the  gauze  and  tubes  were  removed 
within  24  hours. 

On  the  fifth  day  most  of  the  urine  came  through  the  anterior  urethra. 
On  the  10th  day  he  had  perfect  control  and  very  little  urine  came  through 
the  fistula  which  finally  closed  on  the  18th  day.  He  was  up  in  a  chair 
on  the  third  day,  and  began  to  walk  on  the  fourth  day.  Was  discharged 
on  the  26th  day,  wound  closed,  voiding  urine  at  intervals  of  four  hours, 
no  incontinence,  no  pain.  General  condition  excellent,  has  had  no  compli- 
cations. A  silver  catheter  caught  in  a  pouch  in  the  prostatic  urethra  and 
no  further  attempt  was  made  to  obtain  the  residual  urine. 

Urinalysis. — Acid,  slightly  cloudy,  pus  cells  and  bacilli. 

Novemder  30,  1905. — Letter.  I  void  urine  naturally,  about  every  three 
hours  during  the  day  and  five  hours  at  night.  I  have  had  no  instrumenta- 
tion, the  wound  has  remained  closed.  I  sometimes  void  10  ounces  at  a 
time,  have  only  a  slight  pain  at  end  of  urination.  Erections  have  not 
returned.  My  general  health  is  good  with  the  exception  of  paralysis 
agitans. 

May  8,  1906. — The  wound  has  remained  healed.  I  void  urine  normally 
at  intervals  of  four  hours  during  the  day.  I  do  not  rise  at  night  to  urinate. 
The  amount  voided  is  sometimes  12  ounces.  I  suffer  no  pain.  Do  not  have 
erections.    My  general  health  is  excellent  and  I  consider  myself  cured. 

September  i-J,  1906. — Letter.  I  void  urine  naturally  at  intervals  of  three 
or  four  hours  and  not  at  all  at  night,  12  ounces  in  amount.  I  have  erec- 
tions and  intercourse,  but  imperfectly,  owing  to  lateral  curvature  of  the 
penis.     I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  174,  consists  of  three  lobes  of 
the  prostate  removed  in  four  pieces,  and  weighs  (j-25.  The  lateral  lobes 
are  about  equal  in  size  and  measure  4  x  2.5  x  2  cm.  and  each  has  been 
removed  in  one  piece.  The  outer  surfaces  are  smooth,  but  the  inner 
surfaces  are  somewhat  torn  and  lobulated,  and  there  is  considerable 
stroma,  and  little  gland  tissue.  The  median  lobe  was  very  small  and 
has  been  lost.  The  anterior  lobe  forms  a  globular  mass  about  2  cm.  in 
diameter,  and  is  similar  in  character  to  the  rest  of  the  prostate.  There 
is  no  suggestion  of  malignancy.  No  mucous  membrane,  no  ejaculatory 
ducts.     Three  calculi  have  been  removed  as  described  in  the  operation. 

Microscopic    examination. — Section     from     the     left     lobe,     which     ap- 


study  of  145  Cases  of  Perineal  Prostatectomy.  3T7 

parently  macroscopically  contains  most  fibrous  tissue,  sho^vs  on 
microscopic  examination  a  rather  less  amount  of  glandular  tissue 
than  normal.  The  acini  are  very  irregular  in  outline,  and  the 
epithelium  is  absent  from  a  great  number  of  them.  There  is  no  marked 
dilatation  of  the  ducts  although  here  and  there  one  is  seen  which 
is  somewhat  larger  than  normal.  Many  of  the  ducts  are  small  and 
compressed.  There  are  quite  a  number  of  corpora  amylacea  seen.  The 
stroma  is  largely  fibrous  in  character  although  a  fair  amount  of  smooth 
muscle  fibers  is  present.  There  are  several  areas  of  chronic  prostatitis. 
Prostatitis  is  evidently  of  long  standing  in  these  areas  as  there  is  con- 
siderable chronic  inflammatory  tissue  formed,  especially  periglandular. 
The  areas  of  prostatitis  are  comparatively  few  and  small. 

The  hypertrophy  is  of  the  flbro-myomatous  type,  there  being  compar- 
atively no  glandular  increase,  and  the  fibrous  tissue  predominating. 

Case  105. — Moderate  enlargement  of  median  and  lateral  lobes.  Indura- 
tion and  enlarged  glands  suggesting  cancer.  Symptoms  not.  Perineal 
enucleation.    Cure.    Followed  12  months. 

No.  967.     H.  D.  P.,.  age  69,  married,  admitted  June  22,  1905. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  15  years  ago  with  frequency  of  urination,  hesitation 
and  straining.  He  came  then  to  the  hospital  where  he  was  irrigated  once 
a  day  for  two  weeks  with  considerable  improvement.  Urination,  however, 
remained  frequent,  generally  three  or  four  times  at  night  and  every  two 
hours  during  the  day,  and  at  times  there  were  attacks  of  irritability, 
associated  with  very  frequent  urination  which  was  relieved  by  catheter- 
ization and  irrigation  of  the  bladder.  He  has  not  had  complete  retention 
of  urine  and  during  the  last  two  years  has  been  unable  to  pass  a  catheter 
to  irrigate  the  bladder.  Five  weeks  ago  epididymitis  of  left  side  came 
on.  He  has  never  had  hematuria  nor  pronounced  pain,  and  has  passed 
no  calculus. 

S.  P. — The  patient  voids  four  times  during  the  night,  and  about  every 
one  and  one-half  hours  during  the  day.  He  suffers  no  pain,  no  hematuria, 
no  straining,  has  lost  very  little  weight. 

Sexual  powers. — Erections  present,  intercourse  fairly  normal. 

Examination. — The  patient  is  a  sparely  nourished  man,  with  lips  of 
good  color,  slight  arteriosclerosis.  Heart  and  lungs  are  negative.  Ab- 
domen negative. 

Genitalia. — The  globus  minor  of  left  side  is  considerably  indurated,  and 
there  is  a  varicocele  present. 

Rectal. — The  prostate  is  moderately  enlarged,  the  left  lateral  lobe  being 
larger  than  the  right.  The  surface  is  smooth,  the  consistence  firmer  than 
normal,  but  not  of  stony  hardness.  It  is  slightly  elastic  and  not  tender. 
There  is  slight  induration  at  the  junction  of  the  prostate  and  seminal 
vesicles  on  both  sides  and  several  firm  fibrous  cords  are  felt  extending 
from  the  middle  and  upper  end  of  the  prostate  to  the  pelvic  wall.  The  out- 
Vol.  XIV.— 25. 


378  Hugh  H.  Young. 

lines  of  the  seminal  vesicles  are  difficult  to  make  out  and  there  is  no 
marked  induration.  There  is  no  intervesicular  mass.  The  outer  borders 
of  the  seminal  vesicles  are  adherent  to  the  lateral  structures  on  both 
sides,  but  not  to  the  rectum  which  is  soft  and  movable.  Several  enlarged 
glands  are  felt  far  up  on  the  left  side  next  to  the  pelvic  wall,  and  in  the 
sacral  fossa  several  small  glands  are  felt.  Prostatic  secretion  contains 
a  few  lecithin  cells,  granule  cells,  and  a  moderate  number  of  pus  cells. 

Urinalysis. — Clear,  amber,  acid,  very  few  pus  cells,  and  a  few  short 
bacilli. 

Cystoscopic. — A  small  coude  catheter  passes  with  ease  and  finds  25  cc. 
residual  urine  and  a  contracted  bladder  which  will  hold  only  150  cc.  on 
forced  distention.  The  cystoscope  enters  easily  and  is  not  grasped  by  the 
prostatic  urethra.  It  shows  a  small  sessile  rounded  median  lobe  with  a 
fairly  deep  sulcus  on  each  side.  The  lateral  lobes  are  not  at  all  intra- 
vesically  enlarged.  Both  ureters  are  easily  seen  and  are  apparently  normal. 
With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is  easily  felt, 
there  is  no  subtrigonal  thickening,  the  median  portion  of  the  prostate  is 
considerably  enlarged,  and  the  prostate  feels  quite  hard  around  the  cysto- 
scope. 

Remark. — The  history  did  not  suggest  carcinoma,  but  the  finding  of 
enlarged  glands  and  induration,  while  not  of  stony  hardness,  made  us 
suspicious  of  carcinoma.  The  cystoscope  did  not,  however,  present  the 
picture  of  carcinoma.  It  was  decided  to  do  the  conservative  operation 
on  the  ground  that  if  the  disease  was  carcinomatous  the  case  was  hopeless 
on  account  of  the  involvement  of  the  glands  in  the  sacral  fossa. 

Operation,  June  27,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  prostate  was  easily  separated  from  rectum  leaving  a  fairly 
smooth  posterior  capsule.  Palpation  showed  considerable  induration  in 
both  lobes,  but  in  the  region  of  the  seminal  vesicle  there  was  very  little 
induration.  The  usual  bilateral  capsular  incisions  were  made  and  a  thin 
piece  of  tissue  excised  for  examination.  It  had  a  roughly  granular  appear- 
ance with  small  white  and  yellow  specks  in  a  fibrous  stroma  and  suggested 
carcinoma.  A  frozen  section  made  at  once,  showed  many  areas  of  appar- 
ently benign  adenomatous  hypertrophy,  in  a  few  places  there  were  large 
masses  of  epithelial  cells  packed  together  in  spaces  of  tissue 
and  with  no  appearance  of  normal  glandular  structure.  The 
picture  was  not  typical  of  carcinoma,  but  all  who  saw  it 
thought  it  was  probably  malignant.  Owing  to  the  presence  of 
enlarged  pelvic  and  sacral  glands  the  radical  operation  was  not  at- 
tempted. The  lateral  lobes  were  easily  enucleated,  were  only  moderately 
enlarged,  measuring  3x4x4  cm.  in  size.  The  middle  lobe  was  enucleated 
through  the  left  lateral  cavity,  was  smooth,  round  and  measured  2  cm. 
in  diameter.  The  wound  was  closed  as  usual  with  double  tube  drainage 
and  light  gauze  packs  for  the  lateral  cavities.  The  patient  stood  the 
operation  well,  pulse  at  the  end  being  110.  Infusion  and  irrigation  on 
return  to  ward. 


study  of  llf-5  Cases  of  Perineal  Prostatectomy.  375) 

Convalescence. — The  patient  reacted  well,  and  had  an  uninterrupted 
convalescence,  the  highest  temperature  being  100°.  The  irrigation  was 
discontinued  after  12  hours,  the  gauze  and  tubes  removed  at  the  end  of 
24  hours.  The  patient  was  up  in  a  chair  on  the  second  day.  Urine 
came  through  the  anterior  urethra  on  the  ninth  day,  and  the  perineal 
fistula  closed  on  the  16th  day.  On  the  fourth  day  the  left  epididymis,  which 
had  been  swollen  before  operation  again  became  enlarged  and  tender. 
He  was  discharged  from  the  hospital  on  the  29th  day,  able  to  retain 
urine  for  four  hours,  with  no  incontinence  but  with  considerable  precipit- 
ancy. He  was  free  from  pain  and  the  perineal  wound  tightly  healed. 
Rectal  examination  showed  slight  induration  in  the  region  of  the  seminal 
vesicles,  but  nothing  suggesting  carcinoma.  A  silver  catheter  passed  with 
ease,  no  strictures  present,  no  residual  urine.  Patient  advised  to  take 
urotropin,  drink  water  in  abundance  and  dilate  bladder  by  retaining  urine 
as  long  as  possible. 

Novemlter  30,  1905. — Letter.  The  wound  has  remained  closed,  but  is 
somewhat  tender.  I  void  urine  naturally,  about  once  in  two  hours,  and 
three  to  five  times  at  night.  Generally  three  ounces  at  a  time,  occasionally 
four  and  one-half.  I  have  no  pain.  No  erections.  Have  had  no  treatment. 
Have  gained  in  weight  and  my  health  is  fairly  good. 

May  21,  1906. — Letter.  I  void  urine  naturally,  three  times  during  the 
night  and  at  intervals  of  two  hours  during  the  day,  and  about  three  and 
one-half  ounces  at  a  time.  I  suffer  no  pain,  my  general  health  is  fair. 
I  have  gained  a  little  in  weight,  the  wound  has  remained  closed  and  I 
consider  myself  cured. 

September  15,  1906. — Letter  returned  with  a  report  that  patient  is  trav- 
eling in  Europe  and  enjoying  good  health. 

Pathological  report. — The  specimen,  G.  U.  177,  consists  of  the  three  lobes 
of  the  prostate  removed  in  three  pieces,  and  weighing  about  G-10.  During 
operation  an  incision  was  made  through  the  prostatic  capsule,  and  a  piece 
removed  for  examination.  The  cut  surface  showed  many  fibrous  bands, 
with  intervening  areas  yellowish  in  color,  and  it  was  thought  to  be 
suspicious  of  carcinoma.  Yellowish  dots  were  granular,  raised  above  the 
surface  and  the  intervening  tissue  was  very  hard  and  fibrous.  A  frozen 
section  showed  a  very  peculiar  picture.  There  was  only  a  small  amount  of 
normal  gland  structure,  considerable  fibrous  stroma  with  intervening  round 
cell  infiltration,  and  a  few  areas  with  peculiar  epithelial  cells,  apparently 
infiltrating  the  stroma.  This  was  thought  to  be  carcinoma  although  the 
picture  was  very  unusual. 

The  right  lobe  of  the  specimen  removed  measures  2.5  x  2  x  2  cm.,  is  fairly 
smooth,  encapsulated  externally,  and  internally  where  incised  by  the 
scalpel  shows  numerous  yellowish  dots  in  a  fibrous  stroma;  it  does  not 
grit  under  the  knife,  but  suggests  somewhat  carcinoma.  The  left  lobe  is 
about  2.5  X  1.5  X  1  cm.  in  size  and  is  similar  to  the  right.  The  median  lobe 
measures  about  2  cm.  in  diameter,  and  on  section  the  yellowish  mottling 
is  quite  marked.     No  mucous  membrane,  no  ejaculatory  ducts,  no  calculi. 


380  Hngh  H.  Young. 

Microscopic  examination. — The  section  is  largely  composed  of  fibrous 
and  smooth  muscle  tissue.  There  is  very  little  gland  tissue  present. 
Many  of  the  acini  are  dilated  and  show  intracystic  growth.  In  areas  the 
acini  are  flattened  and  giving  evidence  of  compression;  some  being  almost 
entirely  obliterated.  In  these  areas  of  compressed  acini  there  is  consid- 
erable fibrous  hypoplasia.  In  one  angle  of  the  section  there  is  quite  an 
extensive  prostatitis,  probably  most  marked  about  the  acini,  but  extending 
over  a  considerable  area  in  the  interstitial  tissue.  The  inflammatory  pro- 
cess here  gives  evidence  of  long  standing  as  there  is  considerable  fibrous 
tissue  formation.  This  section  is  that  of  a  fibro-myoma  with  compara- 
tively little  adenomatous  tissue. 

Case  106. — Considerable  hypertrophy  of  lateral  lobes.  Small  median 
bar.  Catheter  life.  Cured  of  obstruction.  No  residual  urine  present. 
Frequent  urination  due  to  cystitis  and  vesical  contracture.  Followed  11 
months. 

No.  956.     C.  K.  D.,  age  64,  widowed,  admitted  June  8,  1905. 

Complaint. — "  Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  seven  years  ago  v/ith  frequency  and  difficulty  of 
urination,  this  gradually  increased  until  he  was  voiding  urine  every  15 
minutes  at  night,  and  every  hour  during  the  day  four  years  ago.  Complete 
retention  of  urine  then  came  on  and  he  was  catheterized.  For  the  next 
three  years  he  was  catheterized  at  bed  time  but  was  able  to  void  in  small 
amounts.  During  the  past  year  retention  of  urine  has  been  complete  and 
the  catheter  has  been  necessary. 

8.  P. — The  patient  is  unable  to  void  and  catheterizes  himself  about  six 
times  a  day,  often  with  considerable  difficulty.  He  suffers  no  pain  except 
when  the  bladder  becomes  full;  no  hematuria.  He  has  been  unable  to 
have  sexual  intercourse  for  two  years,  but  on  rare  occasions  has  an  erection 
"When  the  desire  to  urinate  comes  on. 

Examination. — The  patient  is  well  nourished,  lips  of  good  color.  Chest 
and  abdomen  are  negative. 

Rectal. — The  prostate  is  quite  large,  apparently  about  the  size  of  a 
small  orange,  smooth,  elastic,  no  areas  of  induration,  no  nodules.  The 
upper  end  is  reached  with  difficulty,  and  the  seminal  vesicles  cannot  be 
reached. 

Cystoscopic. — The  retention  of  urine  is  complete.  The  cystoscope  shows 
a  median  bar  and  two  very  large  lateral  lobes  with  a  deep  sulcus  in  front. 
There  are  no  sulci  between  the  lateral  lobes  and  the  median  bar.  The 
bladder  is  trabeculated  and  one  small  diverticulum  is  seen.  No  stone 
present.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is 
easily  felt  and  the  median  portion  of  prostate  is  moderately  increased. 

Urinalysis. — Cloudy,  acid,  1030,  no  albumin,  no  sugar,  microscopically, 
pus  cells  and  bacteria.  Prostatic  secretion  contains  few  lecithins,  many 
large  granule  cells,  a  few  pus  cells,  no  spermatozoa. 

Operation,  June  30,  1905. — Ether.     Perineal  prostatectomy  by  the  usual 


study  of  1J/.5  Cases  of  Perineal  Prostatectomy.  381 

technique.  The  lateral  lobes  which  were  quite  large,  were  easily  enucle- 
ated. A  small  median  lobe  was  enucleated  through  the  left  lateral  cavity, 
a  slight  tear  being  made  in  the  urethra,  but  no  mucous  membrane  being 
removed.  The  ejaculatory  ducts  were  preserved.  The  wound  was  closed 
as  usual  with  double  drainage  and  light  packs  for  the  lateral  cavities. 
Submammary  infusion  and  continuous  irrigation  on  return  to  the  ward. 
The  patient  stood  the  operation  well  and  the  pulse  at  the  end  was  95. 

Convalescence. — The  patient  reacted  well.  The  irrigation  was  continued 
for  eight  hours,  and  the  gauze  and  tubes  were  removed  at  the  end  of  24 
hours.  Considerable  bleeding  followed  this,  and  a  few  hours  later  the 
urethra  became  plugged  with  blood  clots  so  that  a  catheter  had  to  be 
passed.  The  catheter  was  removed  on  the  following  day  and  there  was  no 
more  hemorrhage.  Interval  urination  was  established  immediately  after 
removal  of  the  catheter.  On  the  fourth  day  urine  came  through  the 
anterior  urethra,  but  the  fistula  did  not  close  until  the  15th  day.  On  the 
17th  day  the  patient  complained  of  pain  in  the  bladder,  and  he  was 
catheterized,  about  150  cc.  urine  being  withdrawn.  He  was  catheterized 
again  on  the  following  day.  The  patient  had  a  slight  temperature  until 
July  20.  The  evening  rise  being  between  100  and  100.5°  each  day.  He 
had  no  epididymitis  or  other  complications  to  explain  this.  He  was  dis- 
charged on  the  22d  day  in  good  condition,  able  to  retain  urine  for  three 
hours,  and  voiding  in  a  free  stream  with  no  incontinence.  A  silver 
catheter  then  passed  with  ease  and  found  18  cc.  residual  urine.  The 
bladder  was  slightly  contracted  and  patient  was  advised  to  drink  water 
in  abundance  and  to  retain  urine  as  long  as  possible  in  order  to  dilate 
the  bladder. 

September  30,  1905. — The  patient  has  enjoyed  good  health  since  the 
operation  three  months  ago,  has  had  no  complications  and  no  treatment 
except  urotropin.  Urine  is  voided  every  two  hours  during  the  day  and 
three  or  four  times  at  night. 

Examination.- — The  urinary  stream  is  large  and  free,  silver  catheter 
meets  no  obstruction  and  finds  15  cc.  residual  urine  and  the  bladder 
capacity  is  360  cc.    The  wound  is  closed. 

November  30,  1905. — Letter.  I  void  urine  naturally  and  freely,  but  too 
frequently  viz.,  about  every  two  hours  night  and  day,  about  four  or  six 
ounces  at  a  time.  I  have  a  slight  pain  just  before  urinating.  The  wound 
is  closed  and  my  general  health  is  good.     I  have  had  no  erections. 

May  10,  1906. — Letter.  I  void  naturally  but  often  during  the  day  and 
night,  the  largest  amount  at  a  time  is  about  two  ounces.  I  suffer  pain 
when  I  hold  my  urine  too  long.  I  do  not  have  erections.  I  have  had  no 
complications  or  treatment  since  operation. 

September  12,  1906. — Letter.  I  void  urine  naturally,  three  or  four  times 
during  the  day  and  once  at  night,  in  normal  amounts.  Erections  and 
sexual  intercourse  are  satisfactory.  My  general  health  is  splendid  and  I 
am  entirely  cured. 


383.  Hugh  H.  Young. 

Case  107. — Moderate  hypertrophy  of  the  median  and  lateral  portions  of 
the  prostate.  Residuum  1150  cc.  Nephritis.  Operative  cure.  Later  dropsy. 
Accidental  death  six  ynonths  after  operation.     Folloxoed  10  months. 

No.  983.     J.  M.  M.,  age  65,  married,  admitted  July  7,  1905. 

Complaint. — "  Frequency  of  urination  and  incontinence." 

Gonorrhcea  once  as  a  young  man. 

Preset  illness  began  two  and  one-half  years  ago  with  increased  fre- 
quency of  urination.  His  condition  gradually  grew  worse  until  one  year 
ago  he  began  to  dribble  and  would  void  every  half  hour  night  and  day. 
Four  months  ago  he  had  considerable  hematuria,  no  pain,  no  gravel.  Six 
weeks  ago  a  catheter  was  passed  and  one  quart  of  urine  withdrawn. 

S.  P. — Urine  is  voided  about  every  half  hour  during  the  day  and  seven 
or  eight  times  at  night  in  small  quantities.  There  is  considerable  precipit- 
ancy, never  any  hesitation.  During  the  night  there  is  almost  constant 
dribbling.    His  appetite  has  not  been  good  and  he  has  lost  27  pounds. 

Sexual  powers. — Has  not  had  erections  for  two  years. 

Examination. — Patient  looks  well  and  his  lips  are  of  good  color.  The 
pulse  is  full,  regular,  and  there  is  very  little  arteriosclerosis. 

Genitalia. — Negative. 

Rectal. — The  prostate  is  only  slightly  enlarged,  smooth,  fairly  soft  at 
apex,  slightly  indurated  at  the  base  particularly  on  the  left  side.  The 
left  seminal  vesicle  is  indurated  slightly  and  there  is  a  small  nodule  at 
its  junction  with  the  prostate.  The  right  seminal  vesicle  and  vas  are  not 
indurated.  There  is  nowhere  induration  of  marked  degree,  no  enlarged 
glands,  no  intravesicular  mass  and  the  posterior  wall  of  the  bladder  feels 
soft. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  1150  cc. 
residual  urine.  The  cystoscope  shows  a  moderate  intravesical  enlargement 
of  the  lateral  lobes  and  a  slightly  rounded  median  lobe  with  a  shallow 
sulcus  on  each  side.  The  ureters  are  easily  seen  and  appear  normal.  The 
bladder  is  trabeculated ;  there  is  a  slight  cystitis,  no  calculus.  With  finger 
In  rectum  and  cystoscope  in  urethra  the  trigone  feels  soft,  the  median 
portion  of  the  prostate  is  slightly  increased. 

Urinalysis. — Cloudy,  alkaline,  1006,  albumin  a  trace,  no  sugar,  micro- 
scopically, pus  cells  and  a  few  casts.  Urea  G-16  to  liter.  Total  solids  G-23 
to  the  liter. 

Preliminary  treatment. — The  patient  was  sent  to  the  hospital  and  cathe- 
terized  two  or  three  times  daily.  He  was  able  to  void  a  small  amount,  but 
the  catheter  frequently  withdrew  800  or  900  cc.  residual  urine,  and  on  the 
day  before  operation  1100  cc.  Catheterization  produced  considerable  ure- 
thral irritation,  but  the  patient's  condition  improved,  the  sp.  gr.  increased 
from  1006  to  1010,  but  the  granular  casts  and  moderate  amount  of  albumin 
were  still  present. 

Operation,  July  21,  190 5. ^Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Both  lateral  lobes  were  moderately  enlarged  and  easily  enucle- 
ated.    A  median  lobe  of  moderate  size,  a  part  of  which  was  suburethral. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  383 

was  removed  through  one  of  the  lateral  cavities  without  removing  any 
of  the  urethra  or  vesical  mucosa.  Two  small  linear  tears  were  made,  but 
the  floor  of  the  urethra  and  ejaculatory  ducts  were  preserved  intact.  The 
wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs  for 
the  lateral  cavities.  The  patient  stood  the  operation  well,  but  his  pulse 
was  quite  rapid,  being  140  at  the  end  and  156  on  return  to  the  ward. 
Infusion  and  continuous  irrigation  on  return  to  ward.  Two  hours  after 
the  operation  the  pulse  was  100  and  the  patient's  condition  excellent. 
The  gauze  was  removed  on  the  day  after  the  operation,  the  irrigation 
was  discontinued  on  the  second  day  and  the  tubes  removed  on  the  fourth 
day.  There  was  no  post-operative  rise  of  temperature.  The  patient  was 
up  on  the  sixth  day.  Urine  began  to  flow  through  the  anterior  urethra 
on  the  13th  day,  the  patient  was  able  to  retain  urine  for  four  or  five  hours, 
and  his  condition  was  good.  He  was  discharged  from  the  hospital  on  the 
40th  day.  The  fistula  was  not  quite  closed,  but  practically  all  of  the 
urine  came  through  the  urethra  in  a  large  stream,  at  intervals  of  four 
hours  without  pain  or  hesitation.  There  was  a  slight  terminal  dribbling 
but  no  incontinence.  Silver  catheter  meets  no  obstruction  and  finds  75  cc. 
residual  urine. 

October  14,  1905. — The  fistula  persists,  but  only  a  few  drops  come 
through  it.  He  voids  urine  freely  without  pain,  at  intervals  of  three  or 
four  hours.    Gets  up  only  twice  at  night. 

Novemher  30,  1905. — Letter.  I  void  urine  naturally,  but  it  comes  with 
little  force.  The  largest  amount  at  one  time  is  four  ounces.  I  urinate 
three  times  during  the  day  and  four  or  five  times  during  the  night.  The 
fistula  is  still  open  and  about  one-half  ounce  comes  through  each  time. 
There  is  a  burning  and  scalding  during  urination. 

December  28,  1905. — I  am  very  weak,  my  breathing  is  short,  I  am 
dropsical,  my  stomach  and  feet  are  very  much  swollen.  I  have  lost  my 
appetite,  my  kidneys  are  not  doing  their  duty.     The  fistula  is  still  open. 

January  27,  1906. — My  condition  is  very  bad  and  I  am  confined  to  my 
room,  I  am  dropsical,  my  feet  and  scrotum  are  swollen,  and  I  measure  47 
inches  around  my  bladder.  My  wound  has  not  closed  yet,  a  portion  of  the 
urine  still  comes  through  it. 

February  19,  1906. — The  patient  was  killed  to-day  by  being  thrown  out  of 
a  buggy. 

Pathological  report. — The  specimen,  G.  U.  182,  consists  of  the  three  lobes 
of  the  prostate  removed  in  four  pieces.  The  lobes  were  not  labeled  and  it 
is  impossible  to  say  what  the  pieces  represent.  The  entire  weight  is 
about  G-20,  and  the  entire  mass  measures  about  5x3x3  cm.,  more  than 
half  of  it  being  in  one  piece.  The  surface  is  fairly  smooth,  and  on 
section  shows  considerable  gland  tissue  and  a  small  amount  of  stroma. 
No  induration  nor  suggestion  of  malignancy.  No  ejaculatory  ducts,  no 
mucous  membrane. 

Microscopic  examination. — Section  from  the  large  lobe.  In  this 
section     the     gland     tissue     is   very     abundant,     and     arranged   mostly 


384  Hugli  H.  Young. 

in  lobules.  The  acini  within  the  lobules  are  only  slightly  di- 
lated, but  there  is  considerable  papillomatous  outgrowth  in  the 
lumina  of  the  ducts.  The  stroma  within  the  lobules  consists  mostly 
of  slender  bands  interlacing  between  the  various  acini.  The  epithelium 
lining  the  acini  is  of  a  cylindrical  type  sometimes  one  layer  deep,  and  in 
other  places  growing  out  in  epithelial  tufts  many  layers  deep.  One  sees 
occasionally  a  few  leucocytes  in  the  lumina  of  the  acini  with  occasional 
areas  of  round  cell  and  polynuclear  cell  infiltration  in  the  stroma.  Oc- 
casionally one  sees  an  acinus  which  is  considerably  dilated,  and  the  epi- 
thelium is  considerably  flattened.  The  stroma  is  composed  of  smooth 
muscle  and  connective  tissue;  the  smooth  muscle  fibers  apparently  being 
largely  concentrically  arranged  about  the  acini  while  the  center  of  the 
stroma  is  largely  connective  tissue.  The  stroma  in  the  glandular  areas 
seems  for  the  most  part  loosely  bound  together,  but  is  much  more  dense 
in  the  less  glandular  areas. 

This  is  a  section  of  a  distinctly  adenomatous  type  of  hypertrophy  with 
some  glandular  dilatation,  and  a  stroma  composed  about  equally  of  muscle 
fibers  and  connective  tissue.  Some  mild  chronic  prostatitis  present, 
evidently  of  not  very  long  standing  as  in  the  areas  of  infiltration  there 
is  no  formation  of  inflammatory  tissue. 

Case  108. — Considerable  enlargement  of  median  and  lateral  lobes.  Cath- 
eter life  for  nine  years.    Cure. 

No.  163.    J.  M.  C,  age  68,  married,  admitted  July  5,  1905. 

Complaint. — "  Prostatic  hypertrophy.     Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  13  years  ago  with  difficulty  in  urination.  This 
gradually  increased  until  complete  retention  of  urine  came  on  nine 
years  ago,  and  since  then  patient  has  led  a  catheter  life.  On  September  19, 
1901,  a  Bottini  operation  was  performed  under  cocaine.  Only  one  cut 
was  made  owing  to  the  breaking  down  of  the  transformer.  The  patient 
was  unable  to  void  after  the  operation  and  nine  days  later  a  second 
attempt  was  made  to  perform  a  Bottini  operation,  but  again  the  apparatus 
failed  to  work.  After  that  the  patient  continued  to  lead  a  catheter  life, 
but  has  been  able  to  void  voluntarily  a  few  drops  of  urine. 

8.  P. — Catheterization  four  to  six  times  daily,  very  little  voluntary 
urination,  no  pain  in  rectum,  bladder  or  perineum.  He  suffers  from  re- 
current epididymitis  brought  on  by  the  use  of  the  catheter. 

Sexual  powers. — Satisfactory. 

Examination. — The  patient  is  a  healthy  looking  man,  with  lips  of  good 
color.  The  lungs  are  slightly  emphysematous  and  the  heart  is  somewhat 
enlarged,  but  otherwise  negative.    The  abdomen  is  negative. 

Genitalia. — The  right  globus  major  is  indurated  and  enlarged  and  there 
is  a  varicocele  of  moderate  size  on  the  left  side  and  the  epididymis  is 
slightly  indurated. 

Rectal. — The  prostate  is  considerably  enlarged,  about  the  size  of  a  small 


study  of  145  Cases  of  Perineal  Prostatectomy.  385 

orange,  smooth,  rounded,  elastic,  no  tenderness,  no  nodules,  no  marked 
induration.  There  is  a  slight  induration  of  the  seminal  vesicles,  no 
enlarged  glands  are  to  be  felt.  The  prostatic  secretion  is  composed  almost 
entirely  of  pus  cells. 

Gystoscopic. — The  catheter  passes  with  ease,  there  is  complete  retention 
of  urine,  the  bladder  is  large.  The  cystoscope  shows  a  very  large  median 
lobe,  a  portion  of  which  is  directed  downward  and  backward  and  lies  upon 
the  trigone  obscuring  the  right  ureter.  It  is  covered  by  rough  granular, 
in  places  papillary  mucous  membrane,  and  at  first  suggested  an  intra- 
vesical tumor,  but  its  connection  with  the  median  lobe  was  easily  made  out 
and  the  bladder  around  seemed  perfectly  healthy.  The  lateral  lobes  are 
moderately  intravesically  enlarged.  The  bladder  is  markedly  trabeculated 
with  numerous  intervening  pouches.  There  is  considerable  cystitis,  but  no 
calculus.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak 
cannot  be  felt  owing  to  the  great  length  of  the  prostate  and  the  consider- 
able size  of  the  median  portion. 

Urinalysis. — Cloudy,  acid,  1020,  no  sugar,  albumin  in  considerable 
amount.    Microscopically,  pus  cells  and  a  few  casts  and  bacilli. 

Operation.  July  24,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  of  considerable  size  but  were  easily 
enucleated.  The  median  lobe  was  very  large  measuring  about  5  cm.  in 
diameter.  It  was  removed  through  the  right  lateral  cavity,  a  small 
portion  of  the  mucous  membrane  covering  it  was  very  adherent  to  it, 
and  was  removed  with  it.  A  small  tear  was  also  made  in  the  urethra  but 
none  was  removed  and  the  ejaculatory  ducts  were  preserved.  The  wound 
was  closed  as  usual  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  Patient  stood  the  operation  well,  his  pulse  at  the  end 
being  80.     Infusion  and  continuous  irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well,  but  on  the  day  after  the 
operation  the  temperature  rose  to  104.3°.  The  pulse,  however,  was  only 
100°  and  after  four  days  the  temperature  remained  normal.  The  irrigation 
continued  for  18  hours,  the  gauze  was  removed  in  24  hours  and  the  tubes 
in  48  hours.  The  patient  was  out  of  bed  in  a  week.  The  urine  came 
through  the  anterior  urethra  on  the  seventh  day,  and  on  the  12th  day  he 
was  able  to  hold  urine  for  four  hours.  The  perineal  fistula  closed  on  the 
16th  day  and  the  patient  was  discharged  from  the  hospital  on  the  19th 
day,  the  wound  healed,  and  voiding  urine  without  pain  or  dribbling,  at 
intervals  of  from  two  to  five  hours.  General  condition  excellent.  A  silver 
catheter  passed  with  ease  and  showed  no  obstruction  or  stricture,  no 
residual  urine. 

November  30,  1905.- — Letter.  The  wound  has  remained  closed,  I  void 
iirine  naturally  at  intervals  of  four  to  five  hours  night  and  day,  in  normal 
amounts.  I  suffer  no  pain,  have  had  no  erections  as  yet.  My  general 
health  is  excellent. 

May  1,  1906. — The  patient  voids  urine  at  intervals  of  six  hours.  Does 
not  void  during  the  night.  There  is  no  incontinence  and  no  pain.  Erec- 
tions have  returned  but  are  still  weak.    The  urine  is  almost  clear. 


386  Uugh  H.  Young. 

Pathological  report. — The  specimen,  G.  U.  184,  consists  of  three  lobes 
of  the  prostate  each  removed  in  one  piece  and  weighs  about  G-55.  The 
lateral  lobes  are  about  equal  in  size  and  measure  3.5  x  2.5  x  2.5  cm. ;  they 
are  fairly  smooth,  encapsulated,  slightly  lobulated  and  on  section  show 
considerable  glandular  tissue  and  also  considerable  amount  of  stroma. 
There  is  no  dilatation  of  the  ducts.  The  middle  lobe  is  larger  than  the 
two  lateral  combined  and  measures  6  x  4.5  x  4  cm.  It  is  irregularly  torn 
and  a  small  area  of  mucous  membrane  is  attached  to  it.  On  section  there 
is  apparently  more  gland  tissue  than  in  the  lateral  lobes.  No  ejaculatory 
ducts,  no  calculi  present. 

Microscopic  examination. — Section  from  the  right  lobe  shows  tissue  in 
which  there  is  a  large  amount  of  stroma.  Here  and  there  are  areas  in 
which  the  gland  tissue  is  fairly  abundant.  The  acini,  as  a  rule,  are  small, 
and  even  in  places  compressed,  although  occasionally  one  sees  an  acinus 
which  is  considerably  dilated,  with  convolutions  of  its  lining  wall.  There 
is  quite  marked  evidence  of  chronic  inflammation  in  the  stroma  with  con- 
siderable formation  of  areas  of  inflammatory  tissue.  This  new  tissue  is 
often  concentrically  arranged  about  the  acini  and  interlacing  in  different 
directions  through  the  interstitial  stroma.  About  a  few  of  the  acini  there 
is  considerable  round  and  polynuclear  cell  infiltration  with  quite  numer- 
ous leucocytes  in  the  lumina  of  the  acini.  There  is  quite  a  fair  amount 
of  smooth  muscle  present  in  the  stroma,  but  the  connective  tissue  would 
seem  to  predominate. 

This  section  is  a  fibro-myo-adenoma  in  which  the  adenomatous  tissue  is 
only  moderate  in  amount,  the  tissue  being  to  a  large  extent  composed 
of  stroma  in  which  the  connective  tissue  predominates. 

Case  109. — Yery  large  hypertrophy  of  median  and  lateral  lobes.  Des- 
perate condition  before  operation.  Uremia.  Operation  to  supply  perineal 
drainage.    Continuation  of  uremia.    Death  twenty-seventh  day. 

No.  992.    J.  S.  O.,  age  73,  widowed,  admitted  July  20,  1905. 

Complaint. — "  Prostatic  enlargement.     Catheter  life." 

No  history  of  gonorrhoea. 

Present  illness. — About  10  years  ago  the  patient  began  to  have  great 
difficulty  in  urination  which  increased  for  two  years  when  he  began  the 
use  of  a  catheter  and  has  been  unable  to  void  since.  He  has  suffered  greatly 
with  pain  in  the  back  but  has  not  lost  much  weight.  Of  late  he  has  had 
great  difficulty  in  passing  his  catheter  and  has  suffered  a  great  deal  and 
become  very  weak. 

8.  P. — He  is  now  being  catheterized  by  his  physician  two  or  three  times 
daily.    He  is  very  weak  and  sick. 

Examination. — The  patient  looks  sick,  has  been  quite  prostrated  by  his 
trip.  His  lips  are  of  fair  color  and  pulse  80,  volume  good,  slight  nodular 
arteriosclerosis.  The  heart,  lungs,  and  abdomen  are  negative.  There  is 
tenderness  over  the  kidneys  which  are  not  palpable. 

Genitalia. — Left  epididymis  is  considerably  indurated.  The  glands  in 
both  groins  are  enlarged. 


study  of  145  Cases  of  Perineal  Prostatectomy.  387 

Rectal. — The  prostate  is  considerably  enlarged,  tlie  left  lobe  being  the 
greater.  The  contour  is  rounded,  in  places  a  little  irregular,  elastic,  fairly 
soft,  except  at  the  upper  end  of  right  lobe  where  it  is  slightly  indurated, 
and  continuous  with  a  small  indurated  mass  which  runs  off  towards  the 
pelvis.  Neither  seminal  vesicle  is  palpable  and  there  is  no  intervesicular 
mass.  The  patient  is  unable  to  void  urine.  A  coude  catheter  passes  easily 
and  finds  500  cc.  of  urine.  The  patient  is  too  sick  for  cystoscopic  exam- 
ination and  is  sent  to  the  hospital  for  preliminary  treatment. 

July  23,  1905. — The  patient  has  been  catheterized  three  times  a  day. 
The  total  amount  of  urine  to-day  was  1050  cc.  Sp.  gr.  1005,  albumin 
considerable,  urea  G-l-l  per  liter.  The  patient  has  been  drowsy  and  often 
very  irrational  and  difficult  to  manage.  To-day  he  had  a  severe  chill, 
temperature  of  102.6°.  The  patient  seems  to  be  going  down  and  operation 
seems  advisable  to  supply  better  drainage. 

Operation,  July  2Jf,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  prostate  was  enormous.  Two  very  large  lateral  lobes  were 
removed  with  ease,  each  in  one  piece,  Fig.  49.  The  median  lobe,  which 
projected  at  least  three  inches  into  the  bladder  was  removed  in  two  pieces, 
one  through  each  lateral  cavity.  The  mucous  membrane  was  very  adher- 
ent to  it,  and  a  small  portion  was  removed.  There  was  very  little  hemor- 
rhage and  the  patient  stood  the  operation  well.  The  wound  was  closed 
with  double  tube  drainage  and  light  packs  for  the  lateral  cavities  as  usual. 
■A  submammary  infusion  was  given  on  the  table  and  continuous  irrigation 
on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well  from  the  operation,  had  no  rise 
of  temperature  and  the  highest  pulse  during  the  next  24  hours  was  94. 
A  second  infusion  was  given  during  the  night,  considerable  urine  was 
secreted.  About  two  hours  after  the  operation  the  patient  pulled  out  the 
tubes,  and  they  were  inserted  again  with  difficulty. 

July  26,  1905. — The  temperature  has  ranged  between  97°  and  100°,  the 
pulse  between  67  and  80.  His  general  condition  is  good,  he  has  taken  much 
water  and  voided  considerable  urine,  but  his  mental  condition  is  bad  and 
not  at  all  improved.  Patient  is  up  in  a  wheel  chair  to-day  and  the  tubes 
have  been  withdrawn. 

August  1,  1905. — The  patient  has  been  up  in  a  wheel  chair  daily.  His 
condition  improved  for  a  while,  but  to-day  he  is  more  stupid.  Plenty  of 
urine  is  voided  through  the  perineal  wound,  and  he  has  drank  considerable 
water  and  been  infused  every  other  day.  His  temperature  has  varied 
between  80°  and  100.5°  and  his  pulse  between  65  and  85. 

August  6, 1905. — Since  last  note  the  patient  has  been  irrational,  extremely 
restless,  has  refused  everything  by  mouth.  He  has  been  fed  through  a 
stomach  tube  and  infused  twice  daily  (too  often).  His  temperature  has 
risen  slightly,  was  102°  last  night.    His  general  condition  is  growing  worse. 

August  13,  1905. — The  patient  has  been  fed  through  a  stomach  tube  two 
or  three  times  a  day  and  given  two  infusions  daily.  Large  quantities  of 
urine  are  passed  through  the  perineal  wound  which  is  clean  and  healing 


388 


Hugh  H.  Young. 


nicely.  His  mental  condition  is  bad,  at  times  very  stupid.  He  has  had 
Cheyne-Stokes  respirations  for  one  week,  and  his  temperature  has  varied 
between  100°  and  103°,  has  not  been  over  100.5°  during  the  past  three 
days. 

August  16,  1905. — Patient  has  not  been  infused  for  several  days.    He  has 
refused  nourishment  and  has  been  fed  through  the  stomach  tube  three 


Fig.   49. — Large  coalescent  median   and   lateral   lobes.     Case  109. 


times  a  day.  For  the  past  two  days  there  has  been  a  marked  oedema  of 
the  hands  and  feet.  He  has  been  very  stupid  and  it  has  been  almost 
impossible  to  arouse  him.    Temperature  this  morning  104.3°. 

August  17,  1905. — The  patient  grew  steadily  worse.  Respirations  were 
bad,  and  at  4.30  this  morning  he  died.    No  autopsy  could  be  obtained. 

Pathological  report. — The  specimen,  G.  U.  183,  consists  of  five  pieces, 
and  weighs  about  G-150.  The  lateral  lobes  have  each  been  removed  in  two 
pieces,  the  smaller  portion  in  each  case  being  intravesical.  The  right 
lateral  lobe   (two  pieces  together)   forms  a  mass  about  7x4x3.5  cm.,  is 


study  of  IJf-S  Cases  of  Perineal  Prostatectomy.  389 

fairly  smooth,  and  on  section  shows  numerous  spheroids  and  a  small 
amount  of  connective  tissue.  The  left  lateral  lobe  is  larger,  measuring 
about  9x6x4  cm.,  but  is  similar  in  character.  The  median  lobe  is  the 
largest  and  measures  9x5x4  cm.,  and  has  been  removed  in  one  piece, 
it  is  similar  in  character  to  the  other  lobes.  No  ejaculatory  ducts,  no 
calculus. 

Microscopic  examination. — The  stroma  and  gland  tissue  are  pres- 
ent in  about  equal  proportions,  the  gland  tissue  being  somewhat 
more  abundant  than  stroma,  especially  in  the  areas  of  lobulation, 
while  outside  of  the  lobules  the  gland  tissue  and  stroma  are 
about  equal  in  proportion.  Within  the  lobules  the  ducts  are  con- 
siderably dilated,  the  stroma  in  many  instances  being  but  thin  bands 
interlacing  between  the  various  acini.  In  the  areas  outside  of  the  lobules 
the  gland  ducts  are  about  normal  in  size  with  comparatively  regular  lumina. 
There  is  some  round  cell  and  polynuclear  cell  interstitial  infiltration,  with 
formation  about  many  of  the  acini  of  a  fair  amount  of  new  connective 
tissue.  The  stroma  is  made  up  in  varying  proportions  of  muscle  fibers 
and  connective  tissue,  the  latter  in  many  areas  predominating.  This  is 
a  rather  adenomatous  type  of  hypertrophy  with  a  fair  amount  of  stroma 
and  a  moderate  amount  of  interstitial  and  peri-glandular  inflammatory 
tissue  formation. 

Case  110. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Complete 
retention  two  weeks.    Cure. 

No.  1114.    C.  M.  F.,  age  76,  married,  seen  in  Buffalo,  N.  Y.,  August  1,  1905. 

Complaint. — "  Complete  retention  of  urine.     Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  three  years  ago  with  frequency  and  difficulty  of 
urination.  This  gradually  increased  until  two  months  ago,  when  retention 
of  urine  became  complete,  but  after  24  hours  he  was  able  to  void  without 
catheterization.  During  the  past  month  he  has  had  to  urinate  three  or 
four  times  every  night,  and  incontinence  has  been  present.  His  only  pain 
has  been  an  occasional  one  in  the  epigastrium.  A  second  retention  of 
urine  came  on  one  week  ago,  and  since  then  he  has  required  catheteriza- 
tion three  or  four  times  daily.  The  patient  suffers  considerable  pain  dur- 
ing catheterization.     Sexual  powers  absent  for  some  time. 

Examination. — (The  patient  is  a  robust  looking  man  with  lips  of  good 
color.  The  heart  and  lungs  are  negative.  The  abdomen  is  large,  and 
there  is  considerable  over-fatness. 

Rectal. — ;The  prostate  is  moderately  hypertrophied,  forming  a  soft, 
rounded  bulging  mass,  not  tender  on  pressure.  There  is  no  induration  in 
the  region  of  the  seminal  vesicles. 

Cystoscopic. — A  coude  silk  catheter  passes  with  ease  and  finds  about 
500  cc.  residual  urine.  Introduction  of  the  cystoscope  was  followed  by  con- 
siderable hemorrhage,  and  it  was  impossible  to  determine  the  condition 
of  the  intravesical  portion  of  the  prostate  or  to  see  whether  a  stone  was 
present. 


390  Hugh  H.  Young. 

Urinalysis. — Acid,  cloudy,  microscopically,  pus  cells  and  bacilli.  Urea 
in  good  amount.    No  evidence  of  poor  renal  function. 

Operation,  August  2,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  enucleated  and  measured  each  5x4x3 
cm.  The  median  lobe  was  removed  through  one  of  the  lateral  cavities  and 
measured  o  x  3  x  2  cm.  The  ejaculatory  ducts  were  preserved  and  only  a 
slight  tear  was  made  in  the  urethra.  Examination  showed  no  stone  in 
the  bladder  and  that  the  prostatic  enlargement  had  been  completely  re- 
moved. The  wound  was  closed  as  usual  with  double  tube  drainage  and 
light  packs  for  the  lateral  cavities.  The  patient  was  given  an  infusion 
during  the  operation  and  continuous  vesical  irrigation  afterward.  The 
amount  of  hemorrhage  was  slight  and  his  condition  was  excellent  at  the 
end. 

Convalescence. — The  patient  reacted  well.  Continuous  irrigation  was 
maintained  for  12  hours,  and  the  gauze  was  removed  on  the  day  after  the 
operation,  and  the  tubes  on  the  next  day.  On  the  third  day  the  patient 
was  in  excellent  condition,  propped  up  in  bed,  suffering  very  little  pain. 
I  then  left  Buffalo. 

IiCtter. — The  highest  temperature  after  the  operation  was  101°.  Fourteen 
days  after  the  operation  epididymitis  set  in  and  delayed  his  convalescence. 
The  perineal  fistula  closed  on  the  42d  day.  The  patient  was  out-of-doors 
in  four  weeks,  voiding  urine  naturally  at  intervals  of  about  two  hours. 
On  October  6  the  other  testicle  began  to  swell,  this  followed  the  passage  of 
sounds  through  the  urethra. 

February  19,  1906. — iThe  wound  has  remained  closed,  I  void  urine  natu- 
rally once  during  the  night  and  every  three  hours  during  the  day,  about 
six  ounces  at  a  time.  I  suffer  no  pain,  do  not  have  erections.  My  general 
health  is  good,  and  I  consider  myself  cured. 

May  8,  1906. — 'Letter.  I  think  I  am  entirely  cured.  I  void  urine  natu- 
rally about  five  times  during  the  day  and  about  once  or  twice  at  night. 
During  the  day  when  the  desire  to  urinate  comes  on  I  must  attend  to  it 
at  once  or  there  may  be  a  slight  leakage.  I  have  never  wet  the  bed  at 
night.  I  suffer  no  pain.  Erections  which  were  absent  before  operation 
have  not  returned.  My  health  is  good.  I  could  not  be  much  better  at  my 
age. 

Pathological  report. — The  specimen,  G.  U.  204,  consists  of  the  three  lat- 
eral lobes  of  the  prostate  removed  each  in  one  piece,  and  weighs  in  all 
about  40  gm.  The  lateral  lobes  are  about  equal  in  size,  encapsulated, 
coarsely  lobulated,  and  on  section  show  considerable  gland  tissue  and  little 
stroma,  the  picture  in  places  being  rather  homogeneous,  in  others  showing 
considerable  spheroid  formation.  Some  of  these  spheroids  are  quite  yellow 
in  color,  and  have  dilated  acini.  The  median  portion  of  the  prostate  meas- 
ures 3  X  3  X  1.5  cm.,  and  has  apparently  more  stroma  than  the  lateral  lobes, 
which  measure  each  about  4  x  4  x  2.3  cm.  No  mucous  membrane,  no  ejac- 
ulatory ducts  present,  no  calculi. 

Microscopic  examination. — Microscopically  the  hypertrophy  is  a  mod- 
erately glandular  one,  the  gland  tissue  at  times  being  arranged  in  spher- 


study  of  lIf-5  Cases  of  Perineal  Prostatectomij.  391 

ical  lobules,  at  other  times  it  is  rather  diffuse.  In  the  spherical  lobule  the 
gland  tissue  is  distinctly  in  excess  of  the  stroma,  but  in  the  areas  outside, 
the  gland  tissue  and  stroma  are  present  in  varying  proportions.  The  al- 
veoli are,  as  a  whole,  moderately  dilated,  although  there  are  many  areas 
where  the  alveoli  are  rather  small.  The  usual  complexity  of  acini  noticed 
in  these  cases  is  also  present,  and  corpora  amylacea  are  seen.  The  stroma 
contains  more  fibrous  than  muscle  tissue,  and  throughout  the  various  por- 
tions of  the  gland  there  is  seen  considerable  round  cell  infiltration  of  the 
stroma  together  with  formation  of  a  fair  amount  of  inflammatory  tissue 
interlacing  in  different  directions. 

Case  111. — Moderate  hypertrophy  of  median  and  lateral  lohes.  Catheter 
life.     Residual  urine  600  cc.     Cured.    Followed  10  months. 

No.  933.     S.  L.,  age  65,  married,  admitted  May  15,  1905. 

Complaint. — ''  Frequency  of  urination  and  dribbling  at  night." 

No  history  of  gonorrhea. 

Present  illness  began  two  years  ago  with  frequency  of  urination,  but  no 
diflBculty  and  no  pain.  Since  then  there  has  been  a  gradual  increase  in  the 
frequency  and  four  months  ago  patient  consulted  a  physician  who  passed 
a  sound  and  gave  him  medicinal  treatment  without  relief.  Incontinence 
of  urine  has  been  present  at  night  for  the  past  three  months. 

S.  P. — The  patient  voids  urine  every  hour  during  the  day  and  three  or 
four  times  at  night,  and,  despite  this,  wets  the  bed  almost  every  night. 
The  patient  voids  urine  in  very  large  amounts  without  hesitation,  no  pain 
and  with  very  little  difficulty.  His  general  health  is  fairly  good,  but  he 
feels  uncomfortable  in  his  abdomen. 

Sexual  poicers. — Has  no  sexual  power.  Imperfect  erections  in  the 
morning. 

Examination. — The  patient  is  well  nourished  with  lips  of  good  color. 
The  lungs  are  negative.  There  is  a  soft  presystolic  murmur  at  apex  and 
systolic  and  diastolic  murmur  at  aortic  area.  Pulse  is  good.  Slight  arterio- 
sclerosis.   Abdomen  is  negative  with  the  exception  of  a  distended  bladder. 

Genitalia. — ^There  is  a  large  varicocele  with  an  atrophic  testicle  on  the 
left  side. 

Rectal. — -The  prostate  is  moderately  hypertrophied,  globular,  smooth, 
soft,  no  nodules,  no  induration  in  region  of  the  seminal  vesicles,  no  tender- 
ness, rectal  mucosa  soft,  no  glands  present. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  600  cc.  residual 
urine.  The  cystoscope  shows  a  fairly  large  median  lobe  with  a  sulcus  on 
each  side.  The  lateral  lobes  are  very  little  intravesically  hypertrophied. 
The  bladder  is  markedly  trabeculated  with  numerous  pouches  and  one 
fairly  large  diverticulum  on  the  right  side.     No  cystitis,  no  calculus. 

Subsequent  treatment. — The  patient  was  given  urotropin  and  advised  to 
go  into  the  hospital  at  once,  but  would  not  consent.  Complete  retention 
of  urine  came  on  during  the  night,  following  cystoscopy  and -cEtheteriza- 
tion  was  necessary.  After  that  he  was  catheterized  onc^more  and  left 
the  city,  promising  to  return  for  operation.     After  thaj/he  did  not  have 


392  Hugli  H.  Young. 

complete  retention,  but  urination  became  gradually  more  frequent,  and 
he  had  considerable  irritation  along  the  urethra.  After  May,  on  account 
of  the  difficulty  of  urination,  he  began  using  a  catheter  at  first  three  times 
a  week  and  recently  twice  daily.  His  general  health  remained  good.  On 
August  9,  1905,  he  returned  for  operation. 

Urinalysis. — Cloudy,  1010,  acid,  no  sugar,  trace  of  albumin,  numerous 
pus  cells,  no  casts.    Urea  15  gm.  to  the  liter. 

Operation.  August  i '/.  190.'/. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  moderately  enlarged,  being  about 
4  cm.  in  diameter  and  rather  firmly  adherent.  A  pedunculated  middle 
lobe  of  moderate  size  was  removed  through  one  of  the  lateral  cavities 
along  with  a  small  area  of  mucous  membrane  which  was  attached  to  it. 
Closure  as  usual.  The  patient  stood  the  operation  well.  Pulse  at  end  90. 
Infusion  and  continuous  irrigation  on  return  to  ward. 

Convalescence. — The  patient  convalesced  well.  The  highest  temperature 
100.7°  on  the  day  following  the  operation,  after  that  practically  normal. 
Continuous  irrigation  was  discontinued  after  12  hours,  gauze  removed  in 
24  hours  and  the  tubes  in  48.  The  patient  was  up  on  the  third  day,  in  ex- 
cellent condition.  The  urine  came  through  the  anterior  urethra  on  the 
12th  day,  and  the  fistula  closed  on  the  16th  day.  He  was  discharged  on 
the  36th  day  in  excellent  condition,  able  to  retain  urine  four  or  five  hours 
with  no  dribbling,  perfect  control,  stream  large,  no  pain. 

Urine. — Sp.  gr.  1010,  pus  cells,  cocci,  no  casts.  A  catheter  passed  with 
ease  and  found  no  residual  urine. 

November  30,  1905. — Letter.  The  wound  has  remained  closed.  I  void 
urine  naturally  every  three  or  four  hours  during  the  day  and  twice  at 
night  in  large  quantity  without  pain  or  irritation.  My  general  health  is 
excellent,  and  I  consider  myself  cured.     Have  had  no  erections. 

February  12,  1906. — The  patient  says  he  feels  well,  voids  urine  at  normal 
intervals,  gets  up  once  at  night,  has  no  pain  and  feels  perfectly  well. 
Urine  is  still  cloudy  and  contains  bacteria. 

March  10,  1906. — The  patient  reports  for  examination.  Wound  has 
remained  closed,  and  he  has  had  no  treatment  except  urotropin  since  op- 
eration. He  drinks  water  in  considerable  amount  and  voids  large  quanti- 
ties of  urine  at  intervals  of  four  hours  night  and  day.  (Arising  at  2  and 
6  a.  m.  to  urinate.)  He  has  no  pain  or  irritation.  Has  had  no  erections. 
His  general  health  is  excellent. 

May  8,  1906.— I  void  urine  naturally  at  intervals  of  four  hours  during 
the  day  and  at  2  a.  m.  and  6  a.  m.  at  night.  I  suffer  no  pain.  I  do  not 
have  erections.  My  general  health  is  fairly  good.  I  have  gained  11  pounds 
since  the  operation.  The  wound  has  remained  healed,  and  I  consider  my- 
self cured. 

September  1.5.  1906. — Patient  reports  that  he  is  perfectly  well  and  en- 
joying good  health. 

Pathological  report. — The  specimen,  G.  U.  206,  consists  of  five  pieces, 
comprising  both  lateral  and  middle  lobes.  Total  weight  about  18  gm.     It  is 


study  of  llt-o  Cases  of  Perineal  Prostatectomy.  393 

soft  and  elastic  in  consistence  and  on  section  is  made  up  of  numerous 
sptieroids.  The  ejaculatory  ducts  have  not  been  removed.  No  calculus 
present. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated,  moderately 
glandular  one.  Some  of  the  acini  are  dilated  with  quite  extensive  intra- 
acinous  proliferation.  The  epithelium  lining  the  acini  is  often  many  layers 
thick,  and  the  lumina  are  frequently  filled  with  degenerated  epithelial 
cells.  The  stroma  shows  some  polynuclear  and  round  cell  infiltration  with, 
in  areas,  marked  periacinous  inflammatory  tissue  formation.  There  is  a 
considerable  amount  of  muscle  present  in  the  stroma.  The  arteries  show 
quite  marked  thickening,  especially  in  the  fibrous  areas. 

Case  112. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Cured. 
Folloiced  seven  months. 

No.  1021.     J.  R.  R.,  age  71,  single,  admitted  September  24,  1905. 

Complaint. — "  Catheterism.     Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  10  years  ago  with  slight  difficulty  and  frequency  of 
urination.  Condition  remained  about  the  same  until  one  year  ago  when 
complete  retention  of  urine  came  on,  after  which  he  was  catheterized  for 
two  weeks.  After  that  frequent  and  difficult  urination.  During  the  past 
month  the  patient  has  been  catheterized  twice  daily. 

8.  P. — About  five  hours  after  catheterization  the  patient  is  able  to  void 
urine  in  small  amount  and  afterwards  every  hour  with  great  difficulty 
until  catheterized.  His  only  pain  is  in  the  bladder  when  it  becomes  full, 
no  hematuria,  no  gravel,  has  not  lost  weight.     Sexual  powers  normal. 

Examination. — The  patient  is  well  nourished  with  lips  of  good  color. 
The  arteries  are  slightly  thickened,  but  his  pulse  is  good.  Chest,  abdo- 
men and  genitalia  are  negative. 

Rectal. — The  prostate  is  considerably  and  equilaterally  enlarged,  about 
the  size  of  a  small  orange.  It  is  slightly  irregular,  generally  soft,  in  places 
slightly  indurated.  There  is  no  induration  in  the  region  of  the  seminal 
glands  or  between  them,  and  there  are  no  glands  to  be  felt.  Prostate  is 
not  tender. 

Cystoscopic. — 'A  catheter  passes  with  ease  and  finds  170  cc.  residual 
urine.  The  bladder  is  irritable  and  contracted  and  retaining  only  200  cc. 
The  cystoscope  shows  a  fairly  large  median  lobe  with  slight  intravesical 
lateral  hypertrophy.  There  is  a  deep  sulcus  on  each  side  of  the  middle 
lobe.  Both  ureteral  orifices  are  apparently  normal,  the  bladder  is  slightly 
trabeculated,  considerably  inflamed,  there  is  no  stone  present.  With  finger 
in  rectum  and  cystoscope  in  urethra,  there  is  no  subtrigonal  induration, 
and  the  tissues  beneath  the  cystoscope  in  the  median  portion  are  only  mod- 
erately increased  (cystoscope  probably  in  the  lateral  cleft). 

Urinalysis. — Cloudy,  acid,  1020,  albumin  in  small  amount,  no  sugar. 
Pus  cells  and  bacteria  numerous. 

Operation,  September  25,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.     The  lateral  lobes  were  easily  enucleated  and  measured 


394  Hugli  H.  Young. 

about  2x3x5  cm.  in  size.  The  middle  lobe  was  extracted  in  one  piece 
with  the  right  lateral  lobe  by  means  of  the  tractor  and  measured  3x4x5 
cm.  in  size.  A  'portion  of  the  urethra  on  the  right  side  was  torn  and  re- 
moved. The  floor  of  the  urethra  and  ejaculatory  ducts  were  preserved 
intact.  The  wound  was  closed  as  usual  with  double  tube  drainage  and 
light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well, 
pulse  at  the  end  112.  Submammary  infusion  and  continuous  irrigation 
on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well,  but  had  more  fever  than 
usual,  viz.,  102°  on  the  second  and  third  days,  between  99°  and  100°  for 
the  next  12  days,  and  between  101°  and  102°  for  a  week.  He  was  very 
comfortable,  however,  and  his  condition  was  good  and  there  was  no  ex- 
planation for  the  late  rise  in  temperature.  There  were  no  epididymitis 
or  other  complications.  The  irrigation  continued  for  12  hours,  the  gauze 
was  removed  on  the  day  after  the  operation  and  the  tubes  on  the  follow- 
ing day.  On  the  third  day  the  patient  was  up,  urine  came  through  the  an- 
terior urethra  shortly  after  the  removal  of  the  tubes,  and  the  perineal  fis- 
tula closed  finally  on  the  18th  day.  Interval  urination  was  established 
early,  but  there  was  slight  incontinence  for  three  weeks.  The  patient  was 
discharged  from  the  hospital  on  the  31st  day.  At  that  time  he  could  re- 
tain urine  for  five  hours,  voided  in  a  large  stream  without  hesitation,  was 
free  from  pain  and  had  had  several  firm  erections.  The  wound  was  found 
healed,  a  silver  catheter  met  no  obstruction,  residual  urine  5  cc.  Urine 
still  contained  pus  and  a  small  amount  of  albumin. 

November  30, 1905. — Letter.  The  wound  has  remained  closed,  and  I  void 
urine  as  freely  as  I  ever  did,  three  or  four  times  during  the  day  and  once 
or  twice  at  night,  often  a  pint  at  a  time.  I  have  no  pain  and  consider  my- 
self cured.     1  do  not  have  erections.     My  general  health  is  good. 

May  7,  1906. — 'Letter.  I  void  urine  as  naturally  as  I  ever  did  and  a  pint 
or  more  at  a  time.  I  suffer  no  pain,  I  have  some  erections,  but  not  as 
satisfactory  as  before  operation.  My  general  health  is  very  good.  I  have 
gained  in  weight,  and  I  consider  myself  cured. 

September  13.  1906. — Letter.  I  void  urine  naturally  three  or  four  times 
during  the  day  and  none  at  night,  about  a  pint  at  a  time.  Erections  have 
returned.     General  health  excellent.     I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  186,  consists  of  two  pieces 
and  weighs  about  32  gm.  The  right  lateral  and  median  lobes  have  been 
removed  in  one  piece,  and  are  about  equal  in  size,  each  measuring  4  x  3  x 
2.5  cm.  in  size.  They  are  formed  of  many  spheroids  more  or  less  loosely 
bound  together.  The  section  shows  the  usual  adenomatous  picture  with 
considerable  fibrous  stroma  in  the  median  portion.  The  left  lobe  measures 
5x3x2  cm.;  it  is  similar  in  appearance,  but  apparently  more  glandular 
than  the  rest  of  the  prostate.  Portion  of  the  mucous  membrane  has  been 
removed  with  the  left  lateral  lobe. 

Microscopic  examination. — All  three  lobes  present  microscopically  the 
same  picture.  The  alveoli  are  for  the  most  part  arranged  in  lobules, 
and  the  gland  tissue  is  very  much  in  excess  of  the  stroma.     There  is  con- 


study  of  14.0  Cases  of  Perineal  Prostatectomy.  395 

siderable  cystic  degeneration  present  in  areas,  while  in  others  there  is 
only  moderate  dilatation  with  rather  marked  invagination  and  complexity 
of  the  gland  lumina,  with  papillomatous  outgrowth.  There  seems  to  be 
marked  glandular  proliferation  going  on.  The  stroma  in  many  areas  is 
insignificant  in  amount,  comprising  but  slender  bands  of  muscular  and 
fibrous  tissue.  In  other  portions,  especially  surrounding  the  lobules,  the 
stroma  is  much  more  evident.  Here  and  there  small  areas  of  interstitial 
and  occasionally  periacinous  polynuclear  and  round  cell  infiltration  are 
seen. 

The  hypertrophy  is  of  the  glandular  type  with  slight  cystic  degenera- 
tion and  considerable  gland  proliferation. 

Case  113. — Considerahle  hypertrophy,  particuJarly  of  left  lobe,  tcith  in- 
duration, pain  and  other  symptoms  suggesting  cancer.  Cure.  Followed 
nine  months. 

No.  1325.     H.  H.  M.,  age  64,  married,  admitted  September  5,  1905. 

Complaint. — ■"  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  with  slight  frequency  of  urination  four  years  ago, 
but  he  had  very  little  trouble  until  three  and  one-half  years  ago  when 
complete  retention  of  urine  came  on,  and  he  had  to  be  catheterized  for 
three  weeks.  One  year  later  he  was  again  unable  to  void  and  has  had  to 
use  a  catheter  ever  since.  He  is  able  to  pass  small  amounts,  but  with  great 
difficulty,  straining,  pain  and  burning  along  the  entire  urethra  and  at 
times  in  the  thighs  and  testicles.  Hematuria  has  been  considerable  at 
times  and  patient  has  found  catheter  life  very  disagreeable. 

;S.  P. — The  patient  catheterized  himself  without  regard  to  asepsis  two 
or  three  times  during  the  day  and  once  or  twice  at  night.  Micturition  is 
very  painful  and  difficult.  Erections  have  not  been  present  for  five  years. 
Both  testicles  have  been  swollen. 

Examination. — The  patient  is  well  nourished,  mucous  membranes  of 
good  color.     The  lungs,  heart  and  abdomen  are  negative. 

Rectal. — rThe  prostate  is  considerably  enlarged,  particularly  in  the  left 
lateral  lobe  which  extends  far  upward  in  the  region  of  the  seminal  vesicle, 
but  the  contour  is  oval,  the  surface  smooth.  In  places  it  is  slightly  indu- 
rated, in  others  soft.  The  seminal  vesicle  cannot  be  palpated,  but  two 
small  cordlike  masses  are  felt  extending  jpward  and  outward  from  its 
upper  portion.  The  right  lateral  lobe  is  only  moderately  hypertrophied, 
smooth,  elastic,  and  does  not  extend  upward  into  the  region  of  the  seminal 
vesicle,  which  is  not  indurated.  Both  lobes  are  distinctly  more  tender 
than  usual.  The  rectum  is  not  adherent  and  no  enlarged  glands  are  to 
be  felt. 

Cystoscopic. — The  catheter  passes  with  ease.  Retention  of  urine  is  com- 
plete. Vesical  capacity  is  somewhat  contracted.  The  cystoscope  shows  a 
moderate  enlargement  of  the  left  lateral  lobe,  greater  enlargement  of  the 
right  lateral  lobe  and  a  median  bar  of  moderate  size  continuous  with  the 
right  lateral  lobe,  but  separated  from  the  left  by  a  fairly  deep  sulcus. 
Vol.  XIV.— 26. 


396  Hugh  H.  Young. 

The  mucous  membrane  covering  the  prostate  is  smooth.  The  trigone  and 
ureters  are  easily  seen.  The  bladder  wall  is  markedly  trabeculated,  and 
two  small  diverticula  are  present.  Considerable  inflammation  is  present. 
No  foreign  body.  With  finger  in  rectum  and  cystoscope  in  urethra  there 
is  no  increase  in  the  subtrigonal  tissues  and  the  median  portion  of  the 
prostate  is  only  moderately  thickened. 

Urinalysis. — Cloudy,  alkaline,  1019,  no  sugar,  albumin  a  trace,  urea  8 
gm.  to  liter.  Total  quantity  in  24  hours  1500  cc.  Microscopically,  numer- 
ous pus  cells. 

Operation.  September  6,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  right  lateral  lobe  was  only  moderately  enlarged,  the 
left  was  much  larger  and  projected  well  up  into  the  region  of  the  seminal 
vesicle.     It  was  smooth,  rounded,  encapsulated  and  easily  enucleated. 

The  urethra,  ejaculatory  bridge  and  bladder  were  not  disturbed.  Frozen 
sections  of  the  left  lateral  lobe  during  the  operation  showed  benign  ade- 
noma. The  wound  was  closed  as  usual.  Submanimary  infusion  and  con- 
tinuous irrigation  on  return  to  the  ward.  Patient  stood  the  operation 
well,  the  pulse  being  95  at  the  end. 

Convalescence. — The  temperature  rose  to  101.1°  on  the  day  after  the 
operation,  and  for  a  week  there  was  a  temperature  every  evening  between 
100°  and  101°.  The  patient  was  comfortable  and  had  an  excellent  con- 
valescence. Continuous  irrigation  was  discontinued  after  12  hours,  gauze 
was  removed  24  hours  without  bleeding,  tubes  in  30  hours.  Urine  began 
to  come  through  the  anterior  urethra  on  the  second  day.  The  patient  was 
up  in  a  chair  on  the  third  day  and  walking  on  the  fifth.  The  perineal 
fistula  closed  on  the  ninth  day,  and  he  was  discharged  from  the  hospital 
on  the  twelfth  day.  His  condition  was  excellent,  urination  every  three 
to  four  hours  with  no  incontinence,  good  stream,  only  a  slight  burning  at 
times.     He  had  had  one  erection  after  the  operation. 

Xovemier  30,  1905. — -Letter.  The  wound  has  remained  healed.  I  void 
urine  as  well  as  I  ever  could,  about  four  or  five  times  during  the  day  and 
two  or  three  times  at  night,  often  a  pint  at  a  time.  I  have  no  pain  and 
think  I  am  cured.  I  do  not  have  erections,  have  had  no  complications,  no 
treatment,  have  gained  10  pounds,  and  I  feel  like  a  two-year-old. 

May  7,  1906. — ^Letter.  Urination  is  entirely  normal.  I  void  twice  dur- 
ing the  night,  almost  a  pint  at  a  time.  I  have  no  pain  nor  erections. 
Have  had  no  complications  nor  treatment.  My  general  health  is  good,  I 
am  gaining  in  weight  and  strength,  and  consider  myself  entirely  cured. 

Case  114. — 'Considerable  enlargement  of  median  and  lateral  lobes.  Large 
stone  seen  with  cystoscope,  but  not  found  at  operation.  Result:  Relief  of 
obstruction,  frequency  of  urination  and  pain.  Examination  eight  months 
later.    Stone  seen  and  removed  by  suprapubic  lithotomy . 

No.  1025.     E.  S.,  age  70,  widowed,  admitted  September  8,  1905. 

Complaint. — "  Enlarged  prostate,  catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  three  years  ago  with  marked  precipitancy  and  fre- 


study  of  lJi-5  Cases  of  Perineal  Prostatectomy.  397 

quency  of  urination  during  the  day.  Very  soon  after  his  physician  was 
called,  passed  a  catheter  and  drew  off  over  two  quarts  of  urine,  since  then 
patient  has  not  voided  and  has  used  a  catheter.  He  has  never  had  hema- 
turia, never  passed  gravel.  His  only  pain  has  been  an  occasional  sharp 
pain  at  the  neck  of  the  bladder  and  in  the  rectum  during  defecation. 

8.  P. — 'He  catheterizes  himself  about  every  six  hours.  Cannot  void  at 
all,  occasionally  has  slight  pain  in  the  bladder. 

Sexual  powers. — ^No  erections  for  one  year.     General  health  fairly  good. 

Examination. — The  patient  is  emaciated,  lips  of  good  color,  pulse  regu- 
lar, but  considerable  arteriosclerosis  is  present.  The  heart,  lungs  and  ab- 
domen are  negative.  The  glands  of  both  groins  are  enlarged,  indurated 
but  discreet. 

Genitalia. — The  left  epididymis  is  slightly  indurated  and  enlarged.  There 
is  a  varicocele  present. 

Rectal. — 'Prostate  is  moderately  enlarged,  somewhat  irregular  in  shape, 
particularly  along  the  outer  border  of  the  right  lateral  lobe  where  a  large 
hard  nodule  can  be  felt.  At  the  upper  end  of  this  lobe  is  an  indurated 
mass  one  and  one-half  cm.  wide,  extending  upward  and  outward  into  the 
region  of  the  seminal  vesicle  for  a  distance  of  about  2  cm.  It  is  hard, 
smooth  and  not  tender,  and  no  indurated  cords  are  to  be  felt  above  it. 
The  seminal  vesicles  cannot  be  made  out.  The  left  lateral  lobe  is  larger 
than  the  right  and  regular  in  contour.  Its  consistence  is  elastic,  and  al- 
though it  extends  farther  upward  than  the  right  lobe,  there  is  no  prolonga- 
tion into  the  region  of  the  seminal  vesicle,  which  is  soft.  In  the  intravesi- 
cular  region  nothing  abnormal  is  made  out.  No  enlarged  glands  can  be 
felt  in  the  sacral  fossa  or  left  side  of  the  pelvis.  On  the  right  lateral  wall 
of  the  pelvis  one  hard  gland  is  felt  about  2  cm.  above  the  induration  of  the 
prostate.     The  rectal  wall  is  soft  and  not  adherent. 

Cystoscopic. — A  No.  17  coude  catheter  passes  with  ease.  There  is  no 
roughness  in  the  posterior  urethra  and  the  catheter  is  not  grasped.  Reten- 
tion of  urine  is  complete  and  the  bladder  capacity  is  small,  admitting  only 
150  cc.  The  cystoscope  shows  a  considerable  enlargement  of  both  lateral 
lobes  with  a  deep  sulcus  between  them  anteriorly,  and  a  median  lobe  of 
moderate  size  with  a  deep  sulcus  between  it  and  the  left  lateral  lobe.  Be- 
hind the  median  portion  of  the  prostate  is  a  long,  oval,  white,  slightly  gran- 
ular calculus,  freely  movable  in  the  bladder.  When  the  patient  is  turned 
to  the  left  side  it  rolls  into  the  left  half  of  the  bladder  (see  cystoscopic 
chart.  Case  XV,  "Use  of  Cystoscope,  etc.").  The  bladder  is  considerably 
trabeculated  and  inflamed,  and  considerable  mucus  is  present.  With  the 
finger  in  the  rectum  and  cystoscope  in  the  urethra  the  subtrigonal  tissues 
are  apparently  not  much  increased.  To  the  right  of  the  cystoscope  the 
oval  induration  continuous  with  the  right  lateral  lobe  is  felt.  This  indura- 
tion is  not  of  stony  hardness  and  is  smooth  in  contour.  The  median  por- 
tion is  moderately  increased. 

Operation,  September  11,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  posterior  surface  of  the  prostate  was  smooth  and 
not  of  stony  hardness  and  did  not  suggest  carcinoma.     The  lateral  lobes 


398  Hugh  H.  Young. 

were  quite  large  and  easily  enucleated.  On  section  they  appear  benign 
and  a  frozen  section  shows  benign  adenoma.  At  the  upper  end  of  the  right 
lateral  lobe  a  small  oval  lobule  was  found  separately  encapsulated  and  dis- 
tinct from  the  main  body  of  the  right  lateral  lobe.  It  was  evidently  a 
lobule  which  had  broken  through  the  capsule  at  this  point  and  projected 
into  the  region  of  the  seminal  vesicle,  the  frozen  section  showed  it  to  be 
benign.  The  middle  lobe  was  enucleated  through  the  right  lateral  cavity 
without  tearing  the  urethra  or  the  mucous  membrane  of  the  bladder.  The 
lateral  walls  of  the  urethra  were  very  adherent  to  the  lateral  lobes  and  a 
portion  was  removed  on  each  side.  Every  effort  was  made  to  And  the  cal- 
culus which  had  been  seen  with  the  cystoscope,  forceps,  spoons  and  search- 
ers were  used,  but  it  could  not  be  detected.  The  operator,  convinced  that 
he  had  mistaken  a  mass  of  mucous  for  a  stone,  finally  desisted  and  closed 
the  wound,  as  usual,  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  The  patient  stood  the  operation  well.  Pulse  at  the  end 
100.  Submammary  infusion  and  continuous  irrigation  on  return  to  the 
ward. 

Convalescence. — The  patient  reacted  well,  the  temperature  rose  to  103.6" 
five  hours  after  the  operation,  but  rapidly  fell,  rose  to  100.8°  the  next  day 
and  after  that  remained  practically  normal.  Continuous  irrigation  was 
discontinued  after  12  hours,  the  gauze  was  removed  in  24  hours  and  the 
tubes  in  48  hours.  For  two  days  the  urine  came  entirely  through  the 
wound,  the  patient  having  no  control.  On  the  fourth  day  it  began  to  flow 
through  the  anterior  urethra  in  small,  but  rapidly  increasing  amounts. 
The  patient  was  up  on  the  third  day  and  left  the  hospital  on  the  14th  day 
in  excellent  condition.  The  perineal  fistula  was  not  completely  closed. 
Urine  was  voided  about  every  three  hours  in  a  large  stream,  there  was  con- 
siderable urgency  of  urination  but  no  incontinence.  He  was  free  from 
pain  and  had  no  complications.  A  silver  catheter  passed  with  ease,  meet- 
ing no  obstruction,  found  40  cc.  residual  urine,  bladder  capacity  of  230  cc. 
Careful  search  failed  to  detect  a  calculus.  The  urine  was  acid,  quite  puru- 
lent. The  patient  was  advised  to  take  urotropin  and  to  distend  bladder 
by  retaining  urine  as  long  as  possible,  and  to  return  in  a  month  for  cys- 
toscopic  examination. 

November  30.  1905. — 'Letter.  The  fistula  finally  closed  on  35th  day.  The 
wound  is  firmly  closed,  I  void  urine  naturally,  but  frequently,  about  every 
two  hours  during  the  night,  and  every  time  I  get  up  after  sitting  down 
during  the  day.  I  only  pass  about  one-quarter  pint  at  a  time  and  have 
considerable  pain  during  urination.  My  general  health  is  excellent,  and  I 
have  gained  considerably  in  weight. 

May  8.  1906. — Letter.  I  void  urine  about  every  hour  during  the  day.  I 
suffer  a  great  deal  of  pain  during  urination,  particularly  in  walking  down 
hill.  At  night  I  use  the  catheter  three  times,  and  have  about  three  hours 
rest  between  catheterization.  I  have  had  no  erections  since  the  operation. 
My  general  health  is  good  and  I  have  gained  20  pounds.  I  am  benefited, 
but  not  cured. 

May  19,  1906.—  The  patient  returns  for  examination.     The  wound  has 


study  of  1J/.5  Cases  of  Perineal  Prostatectomy.  399 

remained  closed,  but  he  still  voids  urine  at  intervals  of  an  hour  and  with 
pain.  He  catheterizes  himself  at  bedtime,  and  is  then  able  to  sleep  for 
three  or  four  hours.     Has  had  no  erections  since  operation. 

Examination. — ^The  patient  looks  well. 

Rectal. — In  the  region  of  the  prostate  is  a  small  cicatrix,  no  evidence  of 
remaining  hypertrophy. 

Cystoscopic. — The  catheter  passes  with  ease  and  finds  60  cc.  residual 
urine.  The  bladder  is  small  and  irritable  and  will  retain  only  160  cc.  The 
cystoscope  shows  a  large,  oval,  white  vesical  calculus  free  in  the  vesical 
cavity.  The  bladder  is  trabeculated,  no  diverticula  seen.  Study  of  the 
prostatic  orifice  shows  a  somewhat  irregular  margin,  and  in  the  median 
portion  a  small  tentlike  fold  of  mucous  membrane.  There  is  no  definite 
enlargement  present.  With  the  finger  in  rectum  and  cystoscope  in  urethra 
there  is  no  enlargement  of  the  median  portion  made  out. 

May  22,  1906. — -Operation.  Ether.  Suprapubic  lithotomy.  A  large  soft 
calculus  about  4x6x3  cm.  in  size  was  removed.  Examination  of  the  blad- 
der showed  no  remaining  calculus.  The  wall  contained  a  few  cellules,  but 
the  stone  was  not  encysted.  Examination  of  the  prostatic  orifice  showed  a 
smooth  mucous  membrane,  no  intravesical  lobes,  a  small  transverse  fold 
in  the  median  portion  about  1  cm.  high  and  7  mm.  thick.  The  prostatic 
orifice  was  large  and  apparently  no  obstruction  was  present.  It  was 
thought  easy,  however,  to  excise  this  median  fold  and  it  was  caught  be- 
tween two  clamps  and  excised.  A  piece  of  tissue  about  1  cm.  in  diameter 
being  removed.  The  bladder  was  drained  suprapubically  through  a  large 
rubber  tube  which  was  fastened  in  place.  The  patient  stood  the  operation 
well.  Pulse  at  the  end  85.  Infusion  on  return  to  the  ward.  The  tempera- 
ture arose  to  100.8°  on  the  second  day  and  the  patient  was  nauseated  and 
hiccoughed  frequently.  The  suprapubic  tube  was  removed  on  the  third 
day  and  the  patient  was  up  in  a  wheel-chair  on  the  sixth  day.  On  the  10th 
day  a  catheter  was  inserted  into  the  urethra  with  the  hope  of  closing  the 
suprapubic  fistula.  On  the  12th  day  the  urine  was  still  coming  through 
the  suprapubic  fistula,  but  the  patient  asked  to  be  discharged  to  save  ex- 
pense. 

June  9,  1906. — Eighteenth  day.  The  urine  comes  through  the  suprapubic 
fistula.  The  patient  is  comfortable,  but  finds  the  suprapubic  dressings  gen- 
erally wet  and  disagreeable.  He  is  in  good  condition  and  leaves  for  home 
to-day. 

September  14,  1906. — Letter.  I  void  urine  naturally  at  intervals  of  from 
two  to  three  hours,  about  a  gill  at  a  time.  I  have  no  pain.  My  general 
health  is  good  and  I  feel  that  I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  187,  consists  of  the  three  lobes 
of  the  prostate  which  have  been  removed  in  four  pieces  and  weighs  about 
80  gm.  The  right  lobe  measures  5  x  4.5  x  3.5  cm.  Adherent  to  it  is  a  small 
area  of  urethral  mucous  membrane.  It  is  firm,  but  elastic  and  shows  con- 
siderable gland  tissue  and  little  stroma  on  section.  The  left  lateral  lobe 
measures  6  x  4.5  x  2  cm.,  is  lobulated,  elastic,  and  on  section  shows  consid- 
erable gland  tissue  separated  by  a  fibrous  stroma.    The  middle  lobe  meas-; 


400  Hugh  H.  Young. 

ures  3.5  X  2  X  1.5  cm.,  is  covered  by  a  smooth  capsule,  is  elastic  and  glandu- 
lar in  character.  A  small  round  lobe  1.5  cm.  in  diameter,  which  projected 
beyond  the  capsule  at  the  upper  end  of  the  right  lobe  is  smooth  and  on 
section  presents  an  adenomatous  appearance.  Frozen  section  from  this  at 
operation  showed  benign  adenoma. 

Microscopic  examination. — Sections  from  all  three  lobes  show  a  very 
glandular  tissue.  The  acini  are  for  the  most  part  very  much  dilated  and 
lined  with  somewhat  flattened  epithelium.  In  occasional  areas  the  acini 
are  very  slightly,  if  at  all  dilated,  but  the  lumina  are  very  irregular  in 
outline.  Many  of  the  smaller  acini  show  proliferation  of  the  epithelium, 
often  growing  out  in  solid  tufts  into  the  lumen.  The  stroma  is  com- 
paratively small  in  amount,  fairly  compact  and  made  up  in  fairly  equal 
amounts  of  muscle  and  fibrous  tissue.  It  is  an  adenomatous  type  of  hy- 
pertrophy with  considerable  cystic  degeneration,  and  rather  small  amount 
of  stroma. 

Case  115. — ■Considerahle  hypertrophy  of  median  and  lateral  lohes.  Small 
calculus.    Cure.    Followed  seven  months. 

No.  1082.     W.  H.  P.,  age  65,  married,  admitted  October  21,  1905. 

Complaint. — •"  Retention  of  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  eight  months  ago  with  frequency  of  urination. 
Several  months  later  began  to  have  pain  during  ufination  and  sometimes 
a  burning  at  the  end  of  the  penis.  Occasionally  there  was  considerable 
dribbling  after  urination.  Six  days  ago  complete  retention  of  urination 
requiring  catheterization  came  on,  and  since  then  he  has  been  catheterized 
every  six  or  seven  hours.  Sexual  powers  have  been  considerably  weakened 
since  onset  of  trouble,  but  intercourse  is  still  possible. 

Examination. — The  patient  is  a  sturdy  looking  man  with  lips  of  good 
color. 

Heart. — Enlarged  and  there  is  a  soft  blowing  systolic  murmur  at  apex. 
The  lungs  and  abdomen  are  negative.  Genitalia  negative,  with  the  excep- 
tion of  a  profuse  urethral  discharge  which  contains  pus  cells  and  cocci, 
mostly  round.  (This  has  been  present  only  since  catheterization.)  Ar- 
teries are  sclerotic. 

Rectal. — The  prostate  is  considerably  hypertrophied,  forming  a  mass 
w^hich  projects  well  toward  the  rectum.  It  is  smooth,  rounded,  elastic, 
seminal  vesicles  are  palpable  but  not  indurated.  There  is  very  little 
tenderness,  no  enlarged  glands. 

Urinalysis. — -Cloudy,  acid,  1024,  trace  of  albumin^  no  sugar,  no  casts, 
very  little  pus. 

Cysioscopic. — A  coude  catheter  passes  with  ease  and  finds  460  cc.  re- 
sidual urine.  The  cystoscope  shows  considerable  enlargement  of  both  lat- 
eral lobes  with  a  deep  cleft  between  them  anteriorly  and  a  fairly  large 
median  bar  which  is  continuous  with  the  lateral  lobes  on  each  side  with- 
out intervening  sulci.  The  bladder  wall  is  moderately  trabeculated,  with 
shallow  pouches  and  no  definite  diverticula.     Very  little  cystitis.     A  very 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  401 

small  oval,  dark  brown,  moderately  rough  calculus  is  present  behind  the 
interureteral  bar.  The  ureters  are  visible,  and  apparently  normal.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  can  be  felt,  there  is 
no  subtrigonal  thickening.  The  median  portion  is  thicker  than  normal 
and  the  prostatic  length  is  greatly  increased. 

Preliminary  treatment. — ^The  patient  remained  in  the  hospital  for  two 
days  and  was  catheterized  at  intervals  of  from  four  to  six  hours.  The  re- 
sidual urine  varied  from  300  to  500  cc.  A  few  hours  after  catheterization 
the  patient  begins  to  pass  water  with  considerable  straining  and  in  small 
quantities.    Urotropin  and  water  in  abundance  prescribed. 

Operation,  October  2,  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Lithotomy.  The  lateral  lobes  were  considerably  enlarged,  but 
easily  enucleated.  A  fairly  large  median  bar  was  easily  removed  through 
the  right  lateral  cavity.  The  floor  of  the  urethra  and  ejaculatory  ducts 
were  preserved  intact,  no  mucous  membrane  was  removed.  The  wound 
was  closed  as  usual  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  The  calculus  was  not  found,  although  a  prolonged  search 
was  made.  Patient  stood  the  operation  well,  pulse  at  the  end  being  120. 
Infusion  and  continuous  irrigation  on  return  to  ward. 

Convalescence. — Patient  reacted  well.  Temperature  rose  to  100.8°  on  the 
day  after  the  operation,  but  after  that  was  normal.  Continuous  irrigation 
was  stopped  after  18  hours.  Gauze  was  removed  in  24  hours,  and  tubes  in 
48.  The  patient  was  up  on  the  third  day.  At  the  end  of  the  week  almost 
all  of  the  urine  came  through  the  penis,  and  the  fistula  finally  closed  on 
the  15th  day.  Patient  was  discharged  on  the  16th  day,  voiding  at  intervals 
of  three  to  four  hours,  good  stream  without  pain,  with  no  incontinence. 
General  condition  excellent.  It  is  possible  that  the  little  calculus  was  re- 
moved in  a  clot  of  blood  and  not  detected. 

December  1,  190-5. — Letter.  I  am  getting  along  very  well.  The  wound 
has  remained  healed  and  urine  comes  as  freely  as  when  I  was  a  boy.  I 
am  gaining  in  flesh  and  strength. 

February  17,  1906. — Letter.  The  wound  has  remained  closed.  I  void 
urine  three  times  during  the  day  and  twice  at  night,  sometimes  a  pint  at 
a  time.  I  suffer  no  pain,  have  had  no  complications,  have  not  had  erec- 
tions.   My  general  health  is  not  good  on  account  of  my  stomach. 

May  7,  1906. — Letter.  I  void  urine  naturally  at  normal  intervals  during 
the  day  and  about  once  at  night,  and  one  pint  at  a  time.  I  have  no  pain, 
no  erections.    My  general  health  is  excellent  and  I  consider  myself  cured. 

September  13,  1906. — Letter.  I  void  urine  naturally  three  or  four  times 
during  the  day  and  once  at  night.  I  suffer  no  pain.  Erections  and  inter- 
course are  fairly  satisfactory  but  somewhat  weakened.  General  health 
good,  am  cured. 

Pathological  report. — The  specimen,  G.  U.  191,  consists  of  three  lobes  of 
the  prostate  removed  in  four  pieces,  and  weighs  about  40  gm.  The  right 
lateral  lobe  is  lobulated,  3  x  2  x  1.5  cm.  The  cut  surface  Is  irregular,  ow- 
ing to  the  protrusion  of  yellowish  lobules  with  trabeculated  fibrous  stroma 
intervening.     One  small  encapsulated  abscess  is  seen.     The  left  lobe  con- 


403  Hugh  H.  Young. 

sists  of  two  pieces,  and  measures  in  all  about  4x2x2  cm.  A  small  piece 
of  mucous  membrane  is  attached  to  it.  On  section  it  is  similar  to  the 
right  lobe.  The  median  lobe  is  an  irregular  mass,  2.5  x  2  x  1  cm.  It  is 
soft,  elastic,  and  on  section  is  granular  with  considerable  fibrous  stroma. 
No  ejaculatory  ducts. 

Microscopic  examination  of  the  left  lateral  lohe. — The  section  contains 
a  fair  sized  lobule  which  is  rich  in  gland  tissue.  Ihe  stroma  between  the 
acini  is  fairly  thick,  and  is  composed  about  equally  of  muscle  and  con- 
nective tissue.  The  epithelial  lining  of  most  of  the  acini  shows  a  redupli- 
cation and  folding,  in  places  assuming  a  papillomatous  type  Many  of  the 
acini  are  moderately  dilated.  Towards  the  periphery  of  the  lobule  some  of 
the  acini  show  a  periacinous  round  cell  infiltration.  The  tissue  outside 
of  the  lobule  contains  comparatively  few  tubules.  Some  of  the  tubules 
are  dilated,  while  there  are  other  areas  where  the  acini  are  compressed 
and  undergoing  atrophy.  The  stroma  is  composed  of  smooth  muscle  fibers 
of  considerable  extent,  but  in  many  areas  the  connective  tissue  hyperplasia 
is  very  abundant.  There  is  considerable  round  cell  infiltration.  The  con- 
nective tissue  hyperplasia  is  especially  marked  about  the  acini  which  are 
compressed.  This  section  may  be  called  a  fibro-myo-adenoma,  the  adeno- 
matous tissue  predominating  in  areas;  and  a  fibro-myoma  in  other  por- 
tions. 

Right  lateral. — The  adenomatous  tissue  predominates  in  this  section. 
Many  of  the  ducts  are  dilated  and  the  lining  epithelium  is  flattened,  in 
other  dilated  ducts  there  is  some  papillomatous  outgrowth.  The  stroma  is 
apparently  composed  about  equally  of  muscle  and  connective  tissue.  In  a 
few  limited  areas  there  is  some  chronic  prostatitis  present,  the  infiltration 
being  most  marked  about  the  acini  and  also  extending  somewhat  into  the 
interstitial  tissue.  In  this  section  the  adenomatous  tissue  distinctly  pre- 
dominates. 

The  "middle  lobe. — The  tissue  here  distinctly  contains  more  stroma  than 
the  lateral  lobes.  Many  of  the  acini  are  quite  markedly  dilated  with  fiat- 
tened  epithelium,  in  other  acini  there  are  some  solid  masses  of  epithelial 
cells  growing  into  the  lumina  of  the  acini.  In  areas  there  has  been  con- 
siderable connective  tissue  hyperplasia  which  has  almost  completely 
replaced  the  acini.  Here  and  there  is  well  marked  round  cell  infiltra- 
tion in  the  stroma.  In  this  section  the  fibrous  tissue  is  more  abundant, 
and  there  is  comparatively  small  amount  of  gland  tissue  present  except 

in  limited  areas. 

* 

Case  116. — Previous  suprapubic  prostatectomy.  Considerable  enlarge- 
ment of  the  left  lateral  lobe.  Vesical  calculi.  Cured.  Followed  eight 
months. 

No.  1160.    H.  J.,  age  65,  married,  admitted  October  6,  1905. 

Complaint. — •"  Frequency  and  painful  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  about  two  and  one-half  years  ago  with  frequent 
and   difficult   urination.     During  the  next  year  he  suffered   considerably 


Study  of  lJj-5  Cases  of  Perineal  Prostatectomy.  403 

from  straining  during  urination,  and  16  months  ago  complete  retention 
of  urine  came  on.  All  attempts  to  catheterize  him  were  unsuccessful,  and 
he  was  aspirated  suprapubically  for  five  days,  when  a  suprapubic  cystot- 
omy was  performed  for  drainage.  Two  months  later  a  suprapubic  pros- 
tatectomy was  performed  in  Canada.  His  convalescence  was  slow,  he  suf- 
fered with  phlebitis  and  epididymitis,  but  ultimately  left  the  hospital  in 
good  condition,  and  has  not  required  catheterization  since.  Urination  has 
been  frequent  and  for  the  last  two  months  there  has  been  considerable 
pain  in  the  neck  of  the  bladder  and  radiating  to  the  end  of  the  penis. 

S.  P. — Urine  is  voided  every  hour  during  the  day  and  three  times  at 
night.     The  act  is  painful,  the  pain  radiating  to  the  end  of  the  penis. 

Sexual  powers. — iHas  had  no  erections  since  suprapubic  prostatectomy. 

Examination.- — The  patient  is  a  well  nourished  man  with  lips  of  good 
color,  no  arteriosclerosis.  The  chest  is  negative,  and  the  abdomen  also 
with  the  exception  of  a  small  suprapubic  scar. 

Genitalia. — 'No  epididymitis,  no  hernia. 

Rectal. — There  is  a  definite  prostatic  enlargement  present,  particularly 
of  the  left  lateral  lobe,  the  upper  end  of  which  is  difficult  to  reach.  The 
right  lateral  lobe  is  definitely  enlarged.  The  general  contour  of  the  pros- 
tate is  round,  surface  smooth,  consistence  elastic,  and  fairly  soft.  The 
seminal  vesicles  are  negative  and  no  enlarged  glands  to  be  felt. 

Uri?ialysis. — 'Cloudy,  1021,  acid,  no  sugar,  trace  of  albumin,  pus  cells, 
no  casts  seen. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  a  small 
amount  of  residual  urine.  The  bladder  capacity  is  somewhat  contracted 
and  very  irritable.  The  cystoscope  shows  a  fairly  considerable  intravesical 
enlargement  of  the  prostate  consisting  of  a  large  left  lateral  lobe,  a  small 
right  lateral  lobe,  and  a  small  median  bar  connecting  the  two  without  in- 
tervening sulci.  The  bladder  was  trabeculated,  inflamed,  and  in  a  pouch 
immediately  behind  the  median  portion  of  the  prostate  five  small  oval 
calculi  are  seen.  With  finger  in  rectum  and  cystoscope  in  urethra  there 
is  a  definite  enlargement  in  the  median  portion  of  the  prostate. 

Operation,  October  6.  1905. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  right  lateral  lobe  of  the  prostate  was  very  small,  about 
21/0  cm.  in  diameter.  The  left  lateral  lobe  was  considerably  enlarged,  and 
after  its  removal  another  large  lobe,  probably  the  intravesical  portion  of 
the  left  lateral  lobe  was  removed.  At  first  it  seemed  that  this  was  a  middle 
lobe  about  5  cm.  in  diameter.  Exploration  with  the  finger  then  showed 
no  remaining  prostatic  hypertrophy.  The  lateral  wall  of  the  urethra  was 
then  incised  longitudinally,  a  stone  forceps  inserted  and  several  small, 
soft,  round  calculi  and  some  detritus  and  fragments  were  removed.  Care- 
ful examination  with  forceps  and  spoon  show  no  remaining  fragments. 
The  wound  was  closed  as  usual  with  double  catheter  drainage  tubes  and 
light  gauze  packs  for  the  lateral  cavities.  Patient  stood  the  operation 
well,  his  temperature  at  the  end  being  85.  Infusion  and  continuous  irri- 
gation on  return  to  ward. 

Convalescence. — ^The  patient  reacted  well,  but  on  the  day  following  the 


404  Hugh  H.  Young. 

operation  the  temperature  rose  to  102.4°;  after  the  third  day  it  remained 
practically  normal.  The  continuous  irrigation  was  discontinued  after  16 
hours,  the  gauze  removed  after  24  hours  and  the  tubes  after  48  hours.  On 
the  second  day  the  patient  complained  of  a  slight  dull  pain  in  the  left 
testicle.  There  was  no  swelling  and  the  pain  disappeared  after  two  days. 
The  urine  continued  to  come  entirely  through  the  perineal  wound  until  the 
14th  day,  when  after  urethral  irrigation  some  urine  came  through  the  an- 
terior urethra.  On  the  18th  day  the  perineal  fistula  closed  completely. 
The  patient  was  discharged  on  the  21st  day,  in  good  condition,  voiding  at 
intervals  of  two  or  three  hours  with  a  good  stream  and  only  a  slight 
burning. 

December  26,  1905. — The  patient  has  had  no  instrumentation  since  opera- 
tion. He  urinates  without  hesitation  and  in  a  large  stream,  at  intervals  of 
three  hours  during  the  day  and  five  hours  at  night.  He  has  perfect  con- 
trol, no  incontinence  of  any  sort,  the  wound  is  healed.  A  catheter  passes 
with  ease,  meets  no  stricture  or  other  evidence  of  obstruction,  and  finds 
no  residual  urine.    Urine  still  contains  pus  cells  and  bacilli. 

March  S,  1906. — The  patient  urinates  about  every  three  hours  during  the 
day  and  once  or  twice  at  night,  usually  with  a  good  full  stream,  but  occa- 
sionally rather  small. 

Examination. — The  patient  voids  with  a  good  stream.  Urine  is  almost 
clear.  A  silver  catheter  passes  with  ease  ,and  finds  5  cc.  residual  urine. 
Bladder  capacity  250  cc.  A  Kollmann  dilator  passes  into  the  bladder  with 
ease  and  is  dilated  up  to  35  F. ;  there  is  no  stricture  present. 

March  22,  1906. — The  patient  thinks  urination  is  more  free  since  dilata- 
tion. He  is  able  to  retain  urine  seven  hours  at  night  and  has  no  inconti- 
nence, but  during  the  day  when  the  desire  comes  on  it  is  imperative,  and 
if  patient  is  very  much  fatigued  a  few  drops  may  escape  involuntarily. 

May  15,  1906. — Letter.  I  void  urine  naturally,  about  six  times  during 
the  day  and  once  at  night,  about  four  or  five  ounces  at  a  time.  I  have 
only  occasionally  a  slight  pain.  I  have  erections  and  satisfactory  sexual 
intercourse,  my  general  health  is  improving.  I  have  gained  in  weight  and 
consider  myself  cured. 

September  25,  1906. — Letter.  I  void  urine  naturallj^  six  or  seven  times 
during  the  day  and  once  or  twice  at  night,  in  normal  amounts.  I  suffer 
no  pain.     Sexual  intercourse  is  satisfactory.     I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  290,  consists  of  three  pieces 
representing  right,  left  and  median  lobes  and  weighs  about  25  gm.  The 
left  lateral  measures  5x4x3  cm.,  surface  is  lobulated,  consistency  some- 
what firm  but  elastic.  On  section  it  is  seen  that  the  tissue  is  made  up  of 
lobules  of  varying  size  separated  by  small  denser  bands  of  tissue.  The 
right  lateral  lobe  measures  3x2x1.5  cm.  and  is  similar  in  character  to 
the  left.  The  median  lobe  is  a  somewhat  rounded  mass  measuring  2.5  x  2 
cm.,  and  is  also  made  up  of  lobules. 

Microscopic  examination. — The  hypertrophy  is  a  glandular  one  with  con- 
siderable cystic  dilatation  of  the  acini  in  certain  lobules.  In  areas  the 
acini   show   considerable  intraacinous   budding.     About  the  periphery  of 


Study  of  145  Cases  of  Perineal  Prostatectomy.  405 

the  lobule  there  is  the  usual  condensation  and  compression  of  acini.  In 
some  lobules  the  acini  are  rather  regular  in  outline,  while  in  others  the 
acini  are  serrated  and  present  evidence  of  activity.  The  stroma  is  fairly- 
compact,  and  contains  a  moderate  amount  of  muscle.  Some  few  areas  of 
prostatitis  are  present,  but  these  are  comparatively  insignificant.  The  ar- 
teries show  very  little  change  from  the  normal. 

Case  117. — Moderate  hypertrophy  of  viedian  and  lateral  lobes.  Consid- 
erable pain.    Cure. 

No.  1073.    C.  K.,  age  75,  married,  admitted  October  21,  1905. 
Coinplaint. — ''  Enlarged  prostate." 
No  history  of  gonorrhoea. 

Present  illness  began  18  months  ago  with  slight  increase  in  frequency 
of  urination.  A  little  later  he  had  pain  in  the  urethra  during  urination, 
but  soon  recovered  from  both  these  symptoms.  Four  months  ago  he  had 
chills  and  fever,  of  malarial  character,  associated  with  frequent,  difficult 
and  painful  urination,  during  which  he  was  catheterized,  and  since  then 
he  has  had  gradually  increasing  difficulty.  He  has  had  no  pain  in  the  re- 
gion of  the  kidneys,  no  nausea  or  vomiting. 

8.  P. — Urination  occurs  about  every  half  to  one  hour.  The  stream  is 
small,  urination  difficult  and  slow  and  accompanied  by  pain,  no  hemor- 
rhage. 

Sexual  powers. — No  note  made. 

Examination. — 'The  patient  is  well  nourished,  but  looks  weak  and  his 
lips  are  pale.  The  heart  is  slightly  enlarged,  but  the  sounds  are  clear. 
The  lungs  are  negative.  The  pulse  is  of  good  volume  and  tension.  There 
is  slight  arteriosclerosis.     The  abdomen  is  negative. 

Genitalia. — Complete  inguinal  hernia  on  right  side  well  retained  by 
truss. 

Rectal. — 'The  prostate  is  considerably  enlarged,  rounded,  smooth,  soft, 
and  slightly  tender.  There  is  no  induration  in  the  region  of  the  seminal 
vesicles  nor  in  the  intervesicular  space.     No  enlarged  glands. 

Urinalysis. — Cloudy,  slightly  alkaline,  1014,  albumin  in  moderate  amount, 
no  sugar.     Microscopically,  pus  cells,  no  casts  seen. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  SO  cc.  residual 
urine,  bladder  capacity  of  200  cc.  and  considerable  iiritability.  The  cysto- 
scope  shows  a  small  sessile  rounded  median  lobe.  The  lateral  lobes  are 
very  little  enlarged  intravesically,  and  there  are  no  clefts  between  them 
in  front.  The  bladder  is  considerably  trabeculated  with  numerous  small 
pouches  and  cellules.     The  ureters  cannot  be  seen. 

Preliminary  treatment. — The  patient  remained  in  the  hospital  six  days 
before  operation,  during  which  he  was  catheterized  three  times  daily,  the 
residual  urine  varying  from  150  to  400  cc.  Catheterization  was  very  pain- 
ful and  the  bladder  very  irritable.  Catheterization  afforded  very  little  re- 
lief and  he  frequently  voided,  every  half  hour  night  and  day. 

Operation.  October  21,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.     The  lateral  lobes  were  easily  enucleated  and  measured 


406  Hugli  H.  Young. 

4x5x6  cm.  in  size.  The  median  lobe  was  about  2  cm.  in  diameter  and 
came  away  in  one  piece  with  the  lateral  lobe.  A  tear  was  made  in  the 
urethra  on  each  side,  but  the  floor  and  ejaculatory  bridge  were  preserved. 
Frozen  section  showed  the  benign  nature  of  the  hypertrophy.  The  wound 
was  closed  as  usual  with  double  tube  drainage  and  light  packs  for  the 
lateral  cavities.  The  patient  stood  the  operation  well,  the  pulse  at  the  end 
being  100.     Infusion  and  continuous  irrigation  in  ward. 

Convalescence. — The  patient  reacted  well.  On  the  day  before  the  opera- 
tion he  had  a  temperature  of  101.7°,  on  the  day  after  the  operation  his 
temperature  rose  to  101.8°,  and  on  the  third  day  to  102.8°,  but  it  rapidly 
returned  to  normal  and  remained  so  during  the  rest  of  his  stay  in  the 
hospital.  The  irrigation  was  discontinued  after  12  hours,  the  gauze  was 
removed  at  the  end  of  24  hours  and  the  tubes  48  hours.  Patient  was  up  in 
a  chair  on  the  third  day,  his  general  condition  excellent.  Urine  passed 
through  the  penis  on  the  ninth  day  and  the  perineal  fistula  closed  com- 
pletely on  the  14th  day.  At  that  time  he  was  able  to  retain  urine  for 
three  hours  and  voided  urine  in  a  good  stream  and  had  perfect  control. 
He  was  discharged  from  the  hospital  on  the  18th  day,  voiding  urine  at  in- 
tervals of  from  two  to  four  hours  without  pam,  in  a  good  stream.  The 
catheter  passed  easily  and  showed  no  residual  urine.  His  general  health 
excellent. 

May  9,  1906. — ^Letter.  I  void  urine  naturally  at  normal  intervals  during 
the  day  and  once  at  night,  a  pint  at  a  time.  I  have  no  pain,  no  inconti- 
nence, no  erections.  My  general  health  is  good  and  I  consider  myself 
cured. 

September  15,  1906. — Letter.  I  void  urine  naturally  at  intervals  of 
three  or  four  hours  during  the  day  and  once  at  night,  one  pint  at  a  time. 
No  pain,  no  erections.     My  general  health  is  good.     Cured. 

Pathological  report. — The  specimen,  G.  U.  189,  consists  of  the  middle  and 
two  lateral  lobes  of  the  prostate  and  weighs  about  35  gm.  The  left  lateral 
lobe  is  a  lobulated  elastic  mass,  measuring  4  x  3.5  x  3  cm.  Attached  to  it 
is  a  small  bit  of  urethral  mucous  membrane.  On  section  it  has  a  somewhat 
granular  appearance  with  yellowish  areas  in  a  whiter,  more  fibrous  stroma. 
The  median  lobe  has  been  removed  in  one  piece  with  the  right  lateral, 
and  measures  4x3x2  cm.  in  size.  The  right  lateral  is  about  the  same 
size  as  the  left  and  also  has  a  tag  of  mucous  membrane  attached  to  it.  On 
section  it  appears  to  be  more  fibrous  than  the  right.  No  calculi,  no  ejacu- 
latory ducts. 

Microscopic  examination. — The  tissue  is  of  much  the  same  character  in 
all  three  lobes,  being  almost  entirely  composed  of  stroma.  Here  and  there 
are  seen  occasional  acini,  some  of  which  seem  fairly  normal,  while  about 
others  there  has  been  considerable  connective  tissue  formation  with  com- 
pression and  at  times  almost  complete  disappearance  of  the  acini.  The 
stroma  is  for  the  most  part  smooth  muscle  fibers  with  a  very  small 
amount  of  interlacing  connective  tissue,  except  in  the  limited  areas  about 
acini  where  an  excess  in  the  connective  tissue  elements  is  present.  The 
arteries  show  rather  a  marked  endarteritis. 


study  of  145  Cases  of  Perineal  Prostatedomy.  407 

This  is  a  hypertrophy  in  which  the  muscular  element  predominates, 
bundles  of  pure  muscle  fiber  often  being  present,  and  in  which  the  fibrous 
tissue  is  comparatively  small  in  amount  except  in  areas  as  above  stated. 

Case  118. — Considerable  hypertrophy  of  median  and  lateral  lobes.  Com- 
plication: Epididymitis  slight.     Cure. 

No.  1080.     L.  T.  D.,  age  70,  married,  admitted  October  30,  1905. 

Complaint. — "  Frequency  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  about  two  years  ago  with  dribbling  after  urina- 
tion. No  new  symptoms  developed  until  six  months  ago  when  the  fre- 
quency of  urination  rapidly  increased. 

;S.  P. — The  patient  urinates  every  hour  and  there  is  considerable  drib- 
bling, requiring  the  use  of  absorbent  dressings.  His  only  pain  is  a  slight 
burning  pain  near  the  end  of  the  penis  and  in  the  neck  of  the  bladder  on 
urination.  There  seems  to  be  little  difliculty  of  urination  and  only  some 
hesitation  in  starting  the  flow.  There  has  never  been  complete  retention 
of  urine. 

Sexual  powers  began  to  decline  about  12  months  ago,  no  intercourse  for 
four  months,  no  erections  for  two  months.  His  general  health  has  been 
good. 

Examination. — /The  patient  is  a  sparely  built  but  healthy  looking  man 
with  lips  of  good  color  and  only  moderate  arteriosclerosis.  The  lungs 
are  negative. 

Heart. — There  is  a  soft  systolic  murmur  at  the  base,  but  the  heart  is 
not  enlarged. 

Genitalia. — The  left  epididymis  is  enlarged,  irregularly  indurated.  The 
right  vas  deferens  and  epididymis  are  indurated,  but  smooth  and  not 
tender. 

Rectal. — The  prostate  is  moderately  and  equilaterally  enlarged.  The 
posterior  surface  is  flat,  elastic,  in  places  firmer  than  others,  but  nowhere 
of  stony  induration.  The  contour  is  slightly  irregular,  but  generally  of 
an  oval  shape.  The  seminal  vesicles  are  negative  and  there  is  no  inter- 
vesicular  mass.  One  enlarged  gland  is  felt  along  the  lateral  pelvic  wall. 
The  inguinal  and  deep  iliac  glands  are  not  palpable. 

Cystoscopic. — A  large  coude  catheter  passes  with  ease  and  finds  660  cc. 
residual  urine.  The  cystoscope  shows  a  broad  median  bar  continuous  with- 
out intervening  sulci  with  large  intravesical  lateral  lobes,  the  right  being 
the  larger.  The  cleft  in  front  between  these  lobes  is  wide  and  the  lobes 
are  not  closely  approximated  (possibly  accounting  for  the  dribbling).  The 
bladder  is  moderately  trabeculated,  very  slightly  inflamed.  Numerous 
pouches  and  small  cellules  are  present.  The  left  ureter  is  seen  and  is  ap- 
parently normal.  The  right  ureter  cannot  be  seen,  owing  to  numerous 
pouches  in  the  region  of  its  orifice.  With  finger  in  rectum  and  cystoscope 
in  urethra,  it  is  impossible  to  feel  the  beak,  owing  to  the  considerable  in- 
crease in  the  median  portion. 

Urinalysis. — Cloudy,  acid.  1003,  no  sugar,  albumin  in  small  amount.  Mi- 
croscopically, pus  cells  and  bacilli.     Urea  8  gm.  to  liter. 


408  Hugh  H.  Young. 

Preliminary  treatment. — Catheterization  three  times  daily,  urotropin, 
water  in  abundance.  Before  catheterization  the  bladder  forms  a  definite 
abdominal  tumor,  and  the  patient  voids  urine  in  small  amounts.  From 
200  to  400  cc.  of  residual  urine  was  found. 

Operation,  November  2,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  As  soon  as  the  bilateral  capsular  incisions  were  made 
numerous  seed  calculi  were  encountered.  The  lateral  lobes  were  quite  ad- 
herent, firm,  only  moderately  enlarged,  and  each  was  removed  in  one  piece. 
The  median  lobe  about  3  cm.  in  diameter  was  removed  through  one  of  the 
lateral  cavities,  a  small  piece  of  mucous  membrane  being  excised  with  it. 
Most  of  the  urethra,  including  the  floor  of  the  urethra  and  ducts,  preserved 
intact.  Wound  was  closed  as  usual  with  double  tube  drainage  and  light 
packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well.  Pulse 
at  the  end  80.     Infusion  and  continuous  irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to  101° 
on  the  day  after  the  operation,  and  after  that  varied  from  99=  to  100°.  The 
irrigation  was  discontinued  after  12  hours,  and  the  gauze  and  tubes  re- 
moved 30  hours  after  the  operatipn.  The  patient  was  out  of  bed  on  the 
third  day.  On  the  12th  day  the  right  side  epididymitis  began  and  two 
days  later  the  temperature  rose  to  104.2°,  and  the  patient  complained  of 
nausea  and  headache.  He  was  infused  and  on  the  next  day  the  tempera- 
ture was  normal  and  remained  practically  so  thereafter.  The  epididymitis 
was  slight  in  character  and  disappeared  after  six  days.  The  urine  began 
to  flow  through  the  anterior  urethra  on  the  14th  day,  and  the  perineal 
fistula  was  apparently  closed  on  the  18th,  but  after  two  days  slight  leak- 
age again  occurred.  Discharged  23  days  after  the  operation  in  excellent 
condition.  Voiding  urine  at  intervals  of  two  to  three  hours  without  pain. 
Pin  point  fistula  present  in  perineum.     Epididymitis  gone. 

February  27,  1906. — Letter.  The  wound  has  remained  healed.  I  void 
urine  naturally,  three  times  during  the  day  and  once  or  twice  at  night, 
three  or  four  ounces  at  a  time.  I  have  had  no  erections.  My  general 
health  is  very  good,  I  have  gained  in  weight  and  consider  myself  cured. 

May  7,  1906. — Letter.  I  void  urine  naturally,  three  times  during  the 
day  and  twice  at  night,  about  half  a  pint  at  a  time.  I  suffer  no  pain,  the 
wound  has  remained  healed,  my  general  health  is  excellent.  I  have  no 
erections.     I  consider  myself  perfectly  cured. 

Pathological  report. — The  specimen,  G.  U.  193,  consists  of  three  lobes  of 
the  prostate,  each  removed  in  one  piece  and  weighs  about  30  gm.  The 
left  lobe  measures  3  x  2  x  1.5  cm.,  is  lobulated,  elastic,  and  on  section 
numerous  small  seed-like  calculi  are  seen  in  the  substance  of  the  gland; 
these  vary  in  size  from  a  small  grain  of  sand  to  a  millet  seed,  and  50  are 
seen  in  a  section  through  the  center  of  the  gland.  The  tissue  is  yellowish 
in  color  with  streaks  of  grayish  fibrous  tissue  between.  The  right  lobe  is 
slightly  smaller  than  the  left,  lobulated  and  soft.  At  its  upper  end  there 
is  a  small  portion  of  tissue  which  is  distinctly  firmer,  and  on  section  is 
hemorrhagic  and  granular.     Frozen  sections  were  made  from  this  during 


Study  of  lJf5  Cases  of  Perineal  Prostatectomy.  409 

operation  and  it  showed  much  fibrous  tissue  with  inflammatory  infiltra- 
tion. A  small  piece  of  mucous  membrane  is  attached  to  the  inner  surface 
of  the  right  lobe.  The  middle  lobe  is  irregular,  and  about  3  cm.  in  diame- 
ter. The  surface  is  lobulated,  and  on  its  anterior  aspect  is  a  piece  of  mu- 
cous membrane  2x1  cm.  in  size.    Bjaculatory  ducts  are  not  present. 

Microscopic  examination.— The  tissue  from  all  three  lobes  as  a 
whole  contains  gland  tissue  considerably  in  excess  of  stroma. 
The  glands  are  arranged  somewhat  in  lobules  about  which  the 
stroma  is  somewhat  thickened  and  compact.  Within  the  lobules  the 
acini  are  moderately  dilated  with  rather  flattened  epithelium  and 
a  thin  stroma,  while  in  others  the  ducts  are  not  dilated,  the  stroma  is 
considerably  more  evident  and  the  lumina  of  the  ducts  quite  irregular. 
In  the  interlobular  tissue  the  acini  are  compressed  and  rather  infrequent. 
In  several  good-sized  areas  from  the  right  lobe  there  is  considerable  in- 
flammatory interstitial  infiltration,  evidently  of  long  standing  in  places,  as 
there  is  considerable  new  connective  tissue  formation.  The  stroma,  as  a 
whole,  contains  more  fibrous  than  muscle  tissue.  This  is  an  adenomatous 
type  of  hypertrophy  with  moderate  cystic  degeneration,  and  some  chronic 
interstitial  prostatitis. 

Case  119. — Slight  enlargement  of  median  and  lateral  lobes.  Catheter 
life.  Occasional  incontinence  and  severe  pains  in  legs.  Perineal  prosta- 
tectomy. Removal  of  obstruction.  Natural  urination  at  night.  Inconti- 
nence (partial)  in  the  day.     Followed  seven  months. 

No.  1091.    H.  N.  H.,  age  55,  married,  admitted  November  4,  1905. 

Complaint. — >•'  Prostatic  enlargement.     Catheterism." 

Gonorrhoga  36  years  ago — ^was  perfectly  cured. 

Present  illness  began  about  two  years  ago  with  a  feeling  of  pressure  in 
the  bladder  and  occasional  incontinence  of  urine.  He  was  examined  by  a 
physician  who  diagnosed  prostatic  hypertrophy.  Following  this  he  had 
inflammation  of  the  bladder,  very  difficult  urination  and  has  had  to 
use  a  catheter,  although  retention  of  urine  has  never  been  complete.  He 
has  never  had  any  pain  in  the  bladder  other  than  a  slight  one,  has  not  lost 
weight.     Severe  lightning  pains  in  legs  for  two  years. 

8.  P. — The  catheter  is  used  three  times  a  day,  withdrawing  usually  12 
ounces  of  urine.  Retention  of  urine  is  generally  complete,  but  occasionally 
he  may  void  small  amounts  while  at  stool.  The  catheter  life  is  extremely 
disagreeable  to  him. 

Sexual  powers. — His  desire  is  practically  gone,  has  erections  at  night 
when  the  bladder  becomes  full  and  occasionally  has  intercourse,  but  it  is 
very  unsatisfactory. 

Examination. — Patient  is  a  strong,  well  nourished  man  with  lips  of 
good  color.  The  chest  and  abdomen  are  negative.  The  pulse  is  intermit- 
tent, but  the  volume  and  tension  are  good.     Moderate  arteriosclerosis. 

Rectal. — iThe  prostate  is  only  slightly  hypertrophied,  smooth,  regular, 
elastic,  but  fairly  flrm.  There  are  no  nodules.  The  lobes  extend  some- 
what into  the  region  of  the  seminal  vesicles,  and  there  is  considerable  in- 


410  Hugh  H.  Young. 

duration  at  this  point,  but  it  is  not  prominent  and  does  not  suggest  malig- 
nancy.   No  enlarged  glands  are  felt  and  there  is  no  tenderness. 

Urinalysis. — Cloudy,  1012,  neutral,  no  sugar,  albumin  a  trace.  Micro- 
scopically, pus  cells,  red  blood  corpuscles. 

Cystoscopic. — The  retention  of  urine  is  complete.  A  coude  catheter 
passes  with  ease  and  finds  the  bladder  large.  The  cystoscope  shows  a 
moderate  hypertrophy  of  both  lateral  lobes  with  a  shallow  sulcus  between 
them  in  front,  connected  by  a  thin  median  bar.  On  depressing  the  handle 
of  the  cystoscope  with  the  beak  looking  downward  the  lateral  lobes  come 
together  forming  a  deep  cleft,  behind  which  only  a  small  portion  of  the 
median  bar  is  seen.  On  the  left  side  a  second  lobule  is  seen  projecting 
into  the  urethra  external  to  the  lobule  which  appears  at  the  prostatic  ori- 
fice, so  that  it  is  distinctly  intraurethral.  The  bladder  is  considerably 
trabeculated,  moderately  inflamed,  no  calculus  present.  The  ureteral  ori- 
fices are  normal.  With  the  finger  in  the  rectum  and  cystoscope  in  the 
urethra  the  beak  is  easily  felt,  there  is  no  subtrigonal  induration,  no  in- 
crease in  the  median  portion. 

Operation.  Xoveiader  9,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  Lateral  lobes  were  onlj"  slightly  enlarged,  hard  and  ad- 
herent. A  small  median  bar  was  enucleated  along  with  the  right  lateral 
lobe.  There  was  no  definite  middle  lobe  present  as  shown  by  insertion  of 
the  finger  through  the  urethra.  Small  tear  was  made  in  the  urethra,  but 
the  ejaculatory  ducts  and  floor  of  the  urethra  were  preserved  intact.  The 
wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs  for 
the  lateral  cavities.  The  patient  stood  the  operation  well.  His  pulse  at 
the  end  was  110.  Infusion  and  continuous  irrigation  on  return  to  the 
ward. 

Convalescence. — The  patient  reacted  well.  On  the  second  night  after  the 
operation  the  temperature  arose  to  101.5°,  but  immediately  fell  and  re- 
mained practically,  normal.  The  irrigation  was  discontinued  after  28 
hours  and  the  gauze  and  tubes  after  40  hours.  On  the  third  day  he  had 
several  attacks  of  pain  in  the  bladder  and  urethra  which  were  relieved  by 
urethral  irrigation,  several  clots  being  dislodged  from  the  wound.  No 
subsequent  discomfort.  On  the  third  day  the  patient  was  up  in  a  wheel- 
chair and  in  six  days  was  walking  about  the  ward.  On  the  fifth  day  all  the 
urine  came  through  the  anterior  urethra,  but  subsequently  the  perineal 
wound  opened  again.  The  perineal  fistula  closed  on  the  lAth.  day,  and  the 
patient  was  discharged  on  the  ISth  day.  He  was  then  able  to  retain  urine 
for  six  hours,  and  had  no  nocturnal  incontinence.  During  the  day  there 
was  a  slight  incontinence.  No  epididymitis.  The  wound  was  closed.  A 
silver  catheter  passed  without  meeting  any  obstruction  and  found  no  re- 
sidual urine.  The  urine  was  acid  and  contained  pus  cells.  He  was  in- 
structed to  take  urotropin  and  to  drink  water  in  abundance  and  to  retain 
the  urine  as  long  as  possible. 

Fetruary  20.  1906. — The  patient  returns  for  examination,  complaining 
of  incontinence  of  urine.  He  says  that  he  has  had  no  retention  of  urine 
since  the  operation,  and  no  pain,  but  he  is  unable  to  retain  urine  more 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  411 

than  an  hour  or  so  when  involuntary  leakage  begins.  While  walking 
about  there  is  almost  constant  dribbling  of  urine.  During  the  night  he 
does  not  get  up  to  urinate  and  has  no  incontinence.  "When  he  arises  in 
the  morning  he  voids  a  large  amount  of  urine  in  a  good  stream.  He  has 
had  no  sharp  shooting  pains  in  the  front  of  thighs  which  were  present 
before  operation. 

Rectal. — In  the  region  of  the  prostate  is  a  small  moderately  indurated 
mass,  but  no  prostatic  enlargement.  A  silver  catheter  passes  with  ease. 
No  stricture  present,  no  residual  urine.  The  bladder  capacity  is  large — 
380  cc.     The  tonicity  is  excellent. 

The  cystoscope  shows  a  dilated  irregular  prostatic  orifice  so  that  in 
places  there  is  no  well  defined  margin.  The  urethra  is  apparently  dilated, 
thrown  into  folds.  No  intravesical  prostatic  hypertrophy  is  seen,  but  sev- 
eral irregular  protrusions  of  the  urethral  mucous  membrane,  possibly 
small  spheroid  prostatic  masses,  are  seen  in  the  interior  of  the  urethra. 
There  is  no  median  lobe  or  bar  present,  and  with  finger  in  rectum  and 
cystoscope  in  urethra  the  tissue  between  the  two  is  less  than  normal.  The 
bladder  is  very  little  trabeculated,  no  diverticula,  no  stone  present. 

Examination  by  Dr.  Thomas. — -Pains:  Has  been  subject  to  pains  in  legs 
since  bladder  began  to  trouble  him,  intermittent  and  in  various  places, 
felt  as  if  a  knife  were  thrust  about  and  then  withdrawn.  Does  not  think 
the  skin  was  sensitive  after  them.  Since  operation  has  been  much  better. 
Sexual  power  decreasing  for  two  years.  The  optic  nerves  are  normal, 
pupils  somewhat  eccentric  and  irregular  in  outline.  They  react  to  light 
and  during  accommodation.  The  muscular  strength  and  movements  of 
the  arms  are  normal.  Triceps  and  biceps  reflexes  are  present  on  both 
sides.  The  walk  is  firm  and  station  good  with  feet  together  and  eyes 
open.  When  the  eyes  are  closed  there  is  some  swaying,  but  no  tendency 
to  fall.  No  disturbance  of  sensation  over  sacral  segment.  Gluteal,  cre- 
masteric, and  abdominal  reflexes  are  present.  Knee  kicks  present  on 
both  sides  but  somewhat  subnormal.  Ankle  reflexes  only  obtained  upon 
reinforcement.  No  abnormality  of  sensation.  The  case  is,  I  believe,  one 
of  local  trouble  of  the  bladder.  There  are,  however,  things  that  suggest 
the  possibility  of  tabes,  i.  e.,  the  pains,  which  although  not  perfectly  char- 
acteristic, make  one  think  of  those  in  tabes.  The  deep  reflexes  in  the 
legs  are  decreased,  but  other  than  this  there  are  no  other  objective  findings 
indicative  of  spinal  cord  diseases. 

February  24,  1906. — The  dribbling  continues  when  the  patient  is  on  his 
feet,  but  after  sitting  he  voids  150  cc.  in  a  good  stream.  The  bladder  holds 
300  cc.  on  forced  distention.  The  urine  is  almost  clear  and  contains  a 
little  pus.  The  patient  is  advised  to  dilate  the  bladder  by  hydraulic  press- 
ure twice  daily,  to  keep  quiet  and  wear  a  jock-strap  to  hold  the  penis  up 
against  the  abdomen. 

May  8,  1906. — 'Letter.  My  condition  is  improved  somewhat.  The  bowels 
are  somewhat  torpid  and  require  purgatives.  The  severe  nightly  recur- 
rent pains  have  let  up  and  there  seems  now  to  be  a  girdle  or  section  of 
skin  about  eight  inches  wide  around  the  abdomen  and  back  that  is  ex- 
Vol.  XIV.— 27. 


413  Hugh  H.  Young. 

tremely  sensitive  to  the  touch,  chafing  of  underclothes  and  exposure  to 
the  air.  The  feeling  in  a  way  is  like  that  of  a  burn  from  which  a  dress- 
ing was  suddenly  removed.  The  incontinence  of  urine  is  gradually  lessen- 
ing, and  is  50%  better  than  when  I  saw  you. 

May  S,  1906.— hettev  from  physician.  The  patient  has  been  improved 
in  a  general  way.  The  severe  pain  which  came  on  at  12  p.  m.  or  1  a.  m. 
every  night  for  a  considerable  period,  gradually  subsided,  and  now  has 
entirely  ceased  to  occur.  As  this  pain  gradually  disappeared  a  new  symp- 
tom came  on,  viz.,  a  hypersensitive  condition  of  the  skin  around  the  lower 
abdomen  corresponding  to  the  region  supplied  by  the  lumbar  nerves.  The 
obstinate  constipation  has  disappeared  and  his  control  of  the  bladder  has 
perceptibly  improved.  He  certainly  shows  more  symptoms  of  mcipient 
tabes  now.  He  is  losing  in  weight  and  is  not  able  to  work,  and  is  men- 
tally exceedingly  irritable. 

May  21,  i906.--Letter.  I  void  urine  naturally  once  in  three  or  four 
hours,  and  get  up  not  more  than  once  at  night,  and  sometimes  not  at  all, 
to  urinate.  The  largest  amount  voided  at  one  time  is  nine  ounces.  I 
have  never  had  any  incontinence  at  night,  and  the  occasional  dribbling 
of  urine  which  has  been  present  during  the  day  is  improving. 

September  11,  i906.— Letter.  I  void  urine  naturally  about  four  times 
during  the  day  and  once  at  night,  as  much  as  10  ounces  at  a  time.  No 
pain  no  erections.  Incontinence  during  the  day,  but  none  at  night.  His 
phys'ician  reports  that  the  hypersensitive  condition  which  was  present 
around  the  abdomen  has  increased  and  now  involves  the  chest  as  far  as 
the  second  dorsal  vertebra  and  the  patient  says  he  feels  as  if  there  were 
a  constricting  band  over  this  entire  area.  Lightning  pains  have  been 
present  once.  There  is  a  marked  swaying  when  the  eyes  are  closed,  diffi- 
culty in  walking  at  night  and  ataxic  symptoms  have  increased  consid- 
erably. 

Pathological  report.^The  specimen,  G.  U.  194,  consists  of  the  two  lateral 
lobes  of  the.  prostate  gland  and  one  Cowper's  gland.  The  right  lobe  meas- 
ures 2x3x1.5  cm.,  is  firm,  but  elastic,  and  on  section  numerous  small 
black  calculi  are  seen  in  the  peripheral  portion.  It  is  moderately  glandu- 
lar and  has  considerable  fibrous  stroma.  There  are  some  nodules  which 
are  firm  and  smooth  and  apparently  entirely  fibrous  tissue.  The  left  lat- 
eral lobe  consists  of  two  parts  connected  by  a  narrow  neck  of  tissue.  The 
intravesical  portion  is  quite  lobulated  and  succulent,  and  on  section 
very  glandular.  The  extravesical  portion  seems  to  be  fibrous.  No  mucous 
membrane,  no  ejaculatory  ducts,  no  calculi  removed.  Cowper's  gland  is  a 
small  globular  mass  about  8  mm.  in  diameter  and  is  normal  in  appearance. 
Microscopic  examination.— The  section  shows  a  rather  fibro-mus- 
cular  type  of  hypertrophy  with  small  accumulation  of  gland 
ducts  here  and  there.  In  the  intravesical  portion  of  the  left 
lateral  lobe,  however,  there  is  present  a  fair  amount  of  gland 
tissue.  The  stroma  in  this  latter  tissue  is  very  dense,  contains  a 
large  amount  of  muscle,  and  about  numerous  acini  there  is  considerable 
accumulation  of  round  and  polynuclear  cells.     In  the  right  lateral  lobe 


study  of  145  Cases  of  Perineal  Prostatectomy.  413 

and  extravesical  portion  of  the  left,  ttie  tissue  is  largely  made  up  of  a 
stroma  composed  of  muscle.  The  acini  are  not  at  all  dilated,  but  about 
the  majority  of  them  there  is  a  round  cell  and  polynuclear  cell  infiltration 
which  invades  only  to  a  slight  extent  the  interstitial  stroma.  Some  evi- 
dence of  new  connective  tissue  formation  about  a  few  of  the  acini  is  seen. 
This  is  distinctly  a  myomatous  type  of  hypertrophy,  there  being  a  very 
small  amount  of  fibrous  tissue  present,  and  except  in  one  small  portion 
of  the  left  lateral,  the  gland  tissue  is  rather  sparse.  Some  corpora  amyl- 
acea  are  present  in  the  ducts. 

Case  120. — ■Considerable  enlargement  of  right  lateral  lohe.  Very  little 
residuum.  Contracture  of  bladder.  Painful  erections.  Cure  of  obstruc- 
tion, and  improvement  of  pain  in  posterior  urethra.    Followed  six  months. 

No.  1090.     J.  R.  M.,  age  59,  married,  admitted  November  4,  1905. 

Complaint. — "  Slight  frequency  of  urination.  Frequent  painful  erections 
at  night." 

The  patient  had  gonorrhoea  at  the  age  of  20,  was  apparently  perfectly 
cured,  had  no  further  trouble  until  19  years  ago  when  he  began  to  have 
painful  erections  at  night.  He  would  wake  up  with  pain  in  the  perineum 
and  find  the  penis  erect.  Urination  will  relieve  the  erection  and  the  pain, 
but  in  an  hour  or  two  he  would  be  awakened  again  and  find  the  same  con- 
dition present.  He  was  treated  by  a  physician  and  sounds  were  passed 
twice  a  week  for  a  year  without  relief  of  his  symptoms.  He  has  continued 
to  suffer  as  above  described  for  19  years. 

/S.  P. — The  patient  is  wakened  from  one  to  three  times  every  night  with 
painful  erections  and  has  to  urinate  to  relieve  the  condition.  Occasionally 
a  night  passes  without  having  erections,  and  he  then  may  not  have  to 
urinate  at  all  during  the  night.     Micturition  is  normal  during  the  day. 

Sexual  potcers  are  fairly  normal,  intercourse  satisfactory.  There  is 
hesitancy  at  the  beginning  of  urination  and  the  stream  is  usually  small. 
He  often  has  difficulty  in  urinating  while  in  the  standing  position  and 
usually  sits  down. 

Examination. — Patient  is  a  well  nourished  man,  lips  of  good  color. 
Chest  and  abdomen  negative. 

Rectal. — ^The  prostate  is  distinctly  broader  than  normal  and  the  right 
lobe  is  larger  than  the  left.  The  surface  is  smooth,  firmer  than  normal, 
but  not  markedly  indurated  nor  very  tender.  There  are  no  nodules.  The 
seminal  vesicles  are  not  enlarged  but  are  indurated  at  their  juncture  with 
the  prostate.  There  is  no  intervesicular  mass,  no  enlarged  glands  to  be 
felt.  The  prostatic  secretion  contains  some  pus  cells,  many  lecithins,  few 
granule  cells  and  spermatozoa. 

Urinalysis. — Clear,  acid,  1018,  no  sugar,  no  albumin,  no  pus  cells  or  bac- 
teria.   Urea  16  gm.  to  the  liter. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  35  cc.  residual 
urine.  The  bladder  capacity  is  contracted,  holding  300  cc.  on  forced  dis- 
tention. The  cystoscope  shows  considerable  intravesical  enlargement  of 
the  right  lateral  lobe,  no  intravesical  hypertrophy  of  the  left  lateral  lobe 


414  Hugli  H.  Young. 

and  very  little  median  enlargement,  the  bar  being  replaced  by  a  cleft,  as 
shown  in  the  cystoscopic  pictures  which  are  reproduced  in  the  article  on 
cystoscopy  of  the  prostate  (Fig.  25).  The  bladder  is  very  little  trabecu- 
lated.  There  is  no  pouch  formation  and  no  diverticula,  no  cystitis,  no 
calculus.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is 
easily  felt,  the  median  portion  is  very  slightly  greater  than  normal 

Operation,  November  15,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  left  lateral  lobe,  as  predicted,  was  very  little  en- 
larged, but  it  was  easily  enuclated  in  one  piece.  The  right  lateral  lobe 
was  removed  in  two  pieces,  the  first  being  about  the  size  of  the  left  lat- 
eral lobe,  and  superficial  examination  seemed  to  show  that  everything  had 
been  removed.  On  rotating  the  tractor  and  directing  one  of  the  blades 
upward  a  large  intravesically  projecting  portion  of  the  right  lateral  lobe 
was  found,  engaged  with  the  tractor,  and  drawn  down  into  the  right  lat- 
eral cavity.  It  was  evident  that  the  blade  of  the  tractor  had  slipped  be- 
neath the  anteriorly  projecting  right  lateral  lobe,  as  shown  in  Fig.  36. 
It  was  very  easily  enucleated  without  removing  any  mucous  membrane 
which  covered  it,  and  measured  about  214  x  3  x  5  cm.  in  size.  There  was 
only  a  moderate  amount  of  hemorrhage  and  no  tubes  were  inserted  in  the 
bladder,  as  the  operator  was  anxious  not  to  infect  it.  The  lateral  cavities 
were  lightly  packed  and  the  wound  closed  as  usual.  The  patient  stood  the 
operation  well,  the  pulse  at  the  end  being  100.  Infusion  on  return  to  the 
ward. 

Convalescence. — The  patient  reacted  well  and  had  an  uninterrupted 
convalescence.  Temperature  on  the  night  after  the  operation  was  100.4°, 
but  after  that  was  practically  normal.  There  was  very  little  hemorrhage 
and  urine  passed  through  the  penile  urethra  on  the  night  after  the  opera- 
tion. The  gauze  drains  were  removed  on  the  next  day  and  the  fistula 
closed  on  the  eleventh  day.  On  the  third  day  after  the  operation  the  pa- 
tient was  walking  about  his  room,  and  he  left  the  hospital  on  the  eight- 
eenth day.  Interval  urination  was  established  immediately  after  the  opera- 
tion, being  at  first  two  hours  between  urinations.  After  that  the  interval 
gradually  increased,  and  on  discharge  he  was  voiding  urine  in  a  large 
stream  at  intervals  of  three  hours  with  no  incontinence  and  no  pain.  The 
catheter  passed  with  ease,  meeting  no  obstruction  and  found  85  cc.  re- 
sidual urine.  The  wound  is  tightly  healed.  The  urine  contains  no  pus 
cells,  no  bacteria. 

December  24,  1905. — -Letter.  I  void  urine  naturally  at  2  a.  m.  and  6  a.  m. 
and  about  every  three  hours  during  the  day,  half  a  pint  at  a  time.  I  have 
no  pain.     Erections  have  returned. 

January  10,  1906. — [  can  go  all  night  without  urinating,  stream  is  free 
and  I  have  no  pain.  Erections  seem  to  come  when  the  bladder  is  full.  I 
have  not  had  intercourse  as  yet. 

February  16,  1906. — Letter.  During  the  last  week  I  have  had  no  painful 
erections,  in  fact  my  pain  has  entirely  subsided,  and  I  now  think  it  is 
due  to  gout. 

May  6,  1906. — ^Letter.    I  pass  urine  freely,  which  I  did  not  do  before  the 


study  of  145  Cases  of  Perineal  Prostatectomy.  415 

operation,  but  I  have  a  constant  uneasy  feeling  in  a  sore  spot  in  the  deep 
urethra,  the  same  as  before  operation.  I  void  urine  twice  during  the 
night,  about  half  a  pint  at  a  time.  I  have  no  pain  except  the  constant 
uneasiness  spoken  of  above.  I  have  erections  and  intercourse,  but  it  is 
not  very  satisfactory.  The  seminal  ducts  feel  sore.  The  operation  has 
not  relieved  the  tendency  to  erections  at  night  which  keep  me  from  sleep- 
ing, and  seems  as  though  I  had  neuralgia  in  that  region.  The  irritation 
does  not  come  on  until  after  midnight. 

September  13,  1906. — Letter.  I  void  urine  naturally  four  times  during 
the  day  and  twice  at  night.  I  still  have  painful  erections  which  awaken 
me  during  the  night.  Intercourse  is  not  very  satisfactory,  being  some- 
what painful.  I  have  no  urinary  trouble,  and,  although  I  am  improved 
by  the  operation,  as  regards  painful  erections  I  am  not  entirely  cured. 

Pathological  report.— The  specimen,  G.  U.  199,  consists  of  three  portions, 
a  small  left  lateral  3.5  x  1  x  2  cm.,  a  right  lateral  about  the  same  size  and 
an  oval  lobule,  the  intravesical  portion  of  the  right  lateral  lobe,  3  x  2.5  x  2 
cm.  in  size.  On  section  all  three  portions  are  succulent  and  juicy,  soft 
and  elastic,  and  seem  exceptionally  cellular.  The  surface  has  a  rather 
granular  appearance,  is  yellowish  in  color  with  very  small  intervening 
trabeculse  of  fibrous  tissue.  No  mucous  membrane,  no  ducts,  no  calculi 
removed. 

Microscopic  examination. — The  prostate  shows  in  different  places 
a  mixed  type  of  hypertrophy.  There  are  certain  portions  where 
the  gland  tissue  is  very  abundant,  arranged  in  lobules,  and  the 
acini  in  some  of  the  lobules  quite  dilated.  In  others  the  dila- 
tation is  moderate,  but  the  lumina  of  the  ducts  are  quite  ir- 
regular and  complex.  About  the  lumina  of  the  ducts  very  distinct  mus- 
cular bands  are  noticed,  while  the  intervening  stroma  is  mostly  fibrous. 
The  stroma  in  the  areas  where  the  gland  tissue  is  not  so  markedly  ar- 
ranged in  lobules,  is  composed  about  equally  of  muscle  and  fibrous  tissue, 
and  the  concentric  arrangement  of  the  muscle  fibers  about  the  acini  is  not 
so  marked.  Here  and  there  one  sees  acini  about  which  there  has  been 
considerable  connective  tissue  formation.  There  are  occasional  areas  of 
round  cell  and  polynuclear  cell  infiltration.  In  other  parts  of  the  pros- 
tate the  gland  tissue  is  very  sparse,  and  the  stroma  is  largely  composed 
of  muscle,  in  places  grouped  together  in  almost  pure  bundles  of  muscle. 
Some  of  the  acini  which  are  present  in  this  muscular  portion  are  dilated, 
while  others  are  compressed.  Here  and  there  are  areas  of  round  cell  and 
polynuclear  cell  infiltration  with  some  formation  of  new  connective  tissue. 

We  have  in  this  prostate  a  distinctly  adenomatous  type  with  a  relatively 
small  amount  of  flbro-muscular  stroma  and  a  myomatous  type  in  which 
the  glands  and  connective  tissue  elements  are  insignificant. 

Case  121. — Moderate  enlargement  of  median  and  lateral  lobes.  Cure. 
No  complications.    Followed  six  months. 

No.  1100.    J.  L.,  age  58,  married,  admitted  November  16,  1905. 
Complaint. — ^"Prostatic  trouble." 
No  history  of  gonorrhoea. 


416 


Hug}i  R.  Young. 


Present  illness  began  tv/o  years  ago  with  slight  difficulty  and  frequency 
of  urination  which  gradually  increased  until  January,  1904,  when  he  had 
complete  retention  of  urine,  requiring  catheterization.  Six  months  later 
a  second  retention  after  which  he  was  catheterized  for  a  week.  Since 
then  urination  has  been  more  difficult  and  he  has  catheterized  himself  fre- 
quently on  account  of  complete  retention  of  urine.  For  one  month  the 
catheter  has  been  used  once  daily  and  micturition  about  every  hour.  There 
has  been  a  slight  pain  in  the  bladder,  none  elsewhere.  Hemorrhage  only 
once.     No  loss  of  weight.     General  health  excellent. 

S.  P. — »The  patient  catheterizes  himself  at  bedtime  and  withdraws  about 
a  pint  of  residual  urine,  after  that  does  not  void  until  morning,  but  dur- 
ing the  day  voids  urine  about  every  hour  'Vith  difficulty  and  occasionally 
slight  pain.     Sexual  powers  were  normal  up  to  a  month  ago. 


Fig.  50.— Case  121. 

Examination. — Patient  is  sparely  built,  but  a  healthy  looking  man,  with 
lips  of  good  color.  No  arteriosclerosis.  Pulse  regular  and  of  good  vol- 
ume.    The  chest  and  abdomen  are  negative. 

Genitalia. — Negative. 

Rectal.— Th-Q  prostate  is  slightly  enlarged,  smooth,  in  places  slightly  ir- 
regular, elastic  but  firmer  than  normal,  and  at  the  upper  end  near  the 
juncture  with  the  seminal  vesicles  there  is  a  slight  induration.  The  semi- 
nal vesicles  are  soft  and  not  distended.  No  enlarged  glands  are  to  be 
felt.  Massage  of  the  prostate  shows  a  moderate  amount  of  tenderness, 
there  is  no  intervesicular  mass,  no  induration  in  the  region  of  the  trigone. 

Urinalysis. — Cloudy,  acid,  1027,  albumin  a  trace,  no  sugar,  microscopic- 
ally, pus,  no  casts,  no  bacteria. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  only  100  cc. 


I 


study  of  lJi.5  Cases  of  Perineal  Prostatectomy .  417 

residual  urine.  The  bladder  is  irritable,  rebels  at  300  cc.  and  is  evidently 
slightly  contracted.  The  cystoscope  shows  (Fig.  50)  a  slight  intravesical 
hypertrophy  of  the  lateral  lobes,  and  a  fairly  large  median  lobe  with  a 
sulcus  between  it  and  the  lateral  lobe  on  each  side,  and  seen  unusually 
high  up,  in  RA  and  LA  respectively,  as  shown  in  the  accompanying 
chart.  In  Series  U  the  small  size  of  the  anterior  sulcus  is  seen.  In  the 
pictures  shown  in  the  top  row  of  circles  progressive  views  by  rotating  the 
instrument  from  L.  through  LA,  A,  RA,  to  R  are  shown.  As  seen  here, 
the  commissure  between  the  median  lobe  and  lateral  lobe  occurs  very  far 
forward.  The  bladder  wall  is  only  slightly  trabeculated  and  there  are  no 
diverticula  present.  No  calculus  seen.  The  trigone  and  ureters  cannot 
be  made  out  with  certainty. 

Operation,  November  22,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  moderately  hypertrophied  and 
easily  enucleated.  The  median  lobe  was  about  2i/^  cm.  in  diameter  and 
was  easily  removed  through  the  right  lateral  cavity,  only  a  small  tear 
being  made  in  the  lateral  wall  of  the  urethra  in  extracting  it.  Examina- 
tion with  the  finger  afterward  showed  no  remaining  obstruction.  Owing 
to  the  fact  that  the  bladder  was  sterile  it  was  thought  best  not  to  insert 
rubber  drainage  tubes.  The  lateral  cavities  were  packed  with  gauze  and 
the  skin  wound  was  partially  closed  as  usual.  The  patient  stood  the  op- 
eration well,  pulse  at  the  end  being  100.     Infusion  on  return  to  ward. 

Convalescence. — ^The  patient  reacted  well.  During  the  night  following 
the  operation  the  bladder  became  distended  with  urine,  the  gauze  drains 
were  removed,  but  the  patient  was  still  unable  to  urinate  and  had  to  be 
catheterized.  On  the  following  day  he  was  nauseated  and  vomited  and 
was  given  a  submammary  infusion  and  salt  solution  per  rectum.  On  the 
night  of  the  third  day  retention  of  urine  again  came  on  and  the  patient 
was  catheterized.  After  that  there  was  no  further  retention.  He  was  up 
in  a  wheel  chair  on  the  third  day  and  began  to  walk  on  the  fourth  day. 
Urine  came  through  the  anterior  urethra  on  the  fifth  day  and  in  a  few 
days  most  of  it  came  through  the  meatus.  The  perineal  fistula  healed  on 
the  20th  day,  and  he  left  hospital  on  the  21st  day,  able  to  retain  urine  for 
four  hours,  voided  freely  in  a  large  stream  without  incontinence  or  pain. 
Examination  of  the  urine  showed  no  bacteria,  but  numerous  pus  cells  were 
present. 

April  4,  1906. — I  void  urine  at  normal  intervals  during  the  day  and  do 
not  rise  at  night.  I  have  perfect  control,  no  pain.  Urination  is  entirely 
normal.  Erections  have  returned,  and  sexual  intercourse  has  been  in- 
dulged in.    Ejaculations  are  about  normal. 

June  5,  1906. — ^Letter.  My  condition  remains  excellent.  Urination  is 
normal.     Sexual  intercourse  is  entirely  satisfactory. 

Pathological  report. — The  specimen,  G.  U.  202,  consists  of  three  lobes  of 
the  prostate,  each  of  the  three  lobes  having  been  removed  in  one  piece, 
and  weighs  in  all  15  gm.  The  lateral  lobes  are  equal  in  size  and  measure 
4.5x4x2  cm.  The  external  surfaces  are  encapsulated  and  fairly  smooth, 
they  are  elastic,  and  on  section  show  a  moderate  amount  of  gland  tissue 


418  Hugh  H.  Young. 

and  a  definite  amount  of  stroma.  The  median  portion  of  the  prostate 
measures  2  x  1.5  x  1.3  cm.,  and  is  somewhat  similar  in  appearance  to  the 
lateral  lobes.  No  mucous  membrane,  no  ejaculatory  ducts,  no  calculi  re- 
moved. 

Microscopically  both  lateral  lobes  contain  about  the  same  amount  of 
gland  tissue  which  is  much  in  excess  of  the  stroma.  The  middle  lobe 
contains  distinctly  more  stroma  than  either  of  the  lateral  lobes,  and  the 
gland  tissue  and  stroma  are  present  in  about  equal  amounts.  The  gland 
tissue  is  rather  diffusely  distributed  with  here  and  there  considerable  ag- 
gregations of  alveoli.  There  is  moderate  dilatation  of  the  majority  of  the 
acini  with  here  and  there  some  cystic  dilatation  with  flattening  of  the 
lining  epithelium.  There  are  occasional  areas  in  which  the  alveoli  show 
invagination  and  proliferation.  The  stroma  contains  rather  more  fibrous 
than  muscle  tissue  with  here  and  there  points  of  rather  dense  accumula- 
tion of  some  round  but  more  polynuclear  cells.  About  some  of  the  acini, 
in  circumscribed  areas,  there  is  rather  dense  infiammatory  infiltration 
with  endoglandular  proliferation  and  epithelial  degeneration. 

Case  122. — Yery  large  hypertrophy  of  median  and  lateral  lobes.  Oxa- 
late calculus.    Cure.    Followed  six  months. 

No.  1122.    D.  M.,  age  71,  married,  admitted  December  19,  1905. 

Complaint. — "  Frequent  painful  urination." 

Gonorrhcea  in  early  youth,  no  gleet  or  stricture  subsequently. 

Present  illness  began  10  years  ago  with  a  severe  sharp  pain  in  the  left 
side  and  back  which  radiated  to  the  left  groin  and  testicle.  About  a  month 
later  he  had  a  similar  attack  and  shortly  afterwards  three  other  attacks. 
Since  then  he  has  been  free  from  pain  in  his  side  and  back,  but  has  had 
irritation  in  the  bladder  and  pain  at  the  end  of  urination  referred  to  the 
head  of  the  penis,  and  urination  has  been  more  frequent  than  normal. 
Eight  years  ago  he  had  complete  retention  of  urine  requiring  catheteriza- 
tion, and  since  then  has  been  catheterized  about  20  times  for  this  reason. 

;S.  P. — Urination  every  half  hour  night  and  day,  imperative  and  associ- 
ated with  considerable  pain  at  the  end  of  urination  and  located  in  the 
head  of  the  penis.  Urination  difficult,  stream  small,  amounts  voided  little. 
His  general  health  is  excellent.     No  hematuria. 

Sexual  powers.— -There  has  been  no  sexual  desire  and  no  erections  for 
the  past  two  years. 

Examination. — The  patient  is  a  ruddy,  healthy  looking  man.  There  is 
no  arteriosclerosis.    The  chest  and  abdomen  are  negative. 

Genitalia. — The  left  testicle  is  small  and  indurated,  globus  major  large 
and  indurated,  the  minor  soft.  On  the  right  side  there  is  a  hydrocele 
present  and  the  entire  epididymis  is  considerably  enlarged  and  indurated. 

Rectal. — The  prostate  is  markedly  enlarged,  forming  a  globular  mass 
about  as  large  as  a  good  sized  orange.  It  is  elastic,  not  tender,  and  gen- 
erally smooth.  Lying  on  the  posterior  surface  about  its  middle  are  two 
peculiar  irregular  lobulations  which  seem  to  project  through  the  posterior 
capsule,  and  are  so  close  to  the  rectum  that  they  almost  seem  to  be  in 


study  of  lJj.5  Cases  of  Perineal  Prostatectomy.  419 

the  rectal  wall.  But  the  rectal  mucosa  is  not  adherent  to  them.  The  con- 
sistence o:^  these  small  lobulations  is  firmer  than  that  of  the  prostate,  but 
not  extremely  hard.  The  seminal  vesicles  cannot  be  reached.  No  en- 
larged glands  are  palpable,  prostate  not  tender. 

Cystoscopic. — Coude  catheter  passes  with  ease  and  finds  200  cc.  residual 
urine.  The  bladder  is  very  irritable,  apparently  contracted  and  will  not 
admit  more  than  250  cc.  The  cystoscope  shows  a  large,  irregular  oxalate 
calculus,  freely  movable  in  the  bladder.  Owing  to  hemorrhage  it  is  im- 
possible to  make  out  the  intravesical  portion  of  the  prostate,  but  a  large 
median  lobe  was  made  out. 

Urinalysis. — Slightly  cloudy,  acid,  1016,  albumin  a  trace,  no  sugar,  few 
pus  cells,  many  bacilli,  some  micrococci,  no  casts. 

Preliminary  treatment.- — Catheterization  three  times  daily,  urotropin, 
hydrotherapy. 

Operation,  December  27,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  posterior  surface  of  the  prostate  and  rectum  were 
very  adherent,  and  had  to  be  dissected  apart.  The  irregular  lobules,  felt 
on  rectal  examination,  were  not  seen,  evidently  being  dissected  off  with 
the  rectum.  An  orderly  holding  the  urethral  staff  punctured  the  urethra 
at  tho  beginning  of  the  membranous  portion  and  considerable  diflaculty 
was  experienced  in  finding  the  membranous  urethra  and  introducing  the 
tractor.  The  lateral  lobes  were  enucleated  very  easily,  each  in  one  piece, 
and  were  very  much  enlarged  (Fig.  51).  Quite  a  large  median  lobe  was 
drawn  down  and  removed  through  the  right  lateral  cavity.  The  calculus 
was  extracted  through  the  dilated  prostatic  urethra.  The  wound  was 
closed  as  usual  with  double  tube  drainage  and  light  packs  for  the  lateral 
cavities.  The  patient  stood  the  operation  well;  infusions  and  continuous 
irrigation  on  return  to  ward. 

Convalescence. — The"  patient  reacted  well.  The  gauze  and  tubes  were 
removed  on  the  following  day  and  he  began  to  walk  on  the  fourth  day. 
The  urine  began  to  flow  through  the  urethra  on  the  third  day,  and  the 
patient  was  discharged  from  the  hospital  on  the  30th  day.  At  that  time 
he  was  able  to  retain  urine  for  four  or  six  hours,  had  perfect  control,  no 
pain,  and  felt  well. 

February  21,  1906. — Small  amount  of  urine  escapes  through  a  perineal 
fistula  with  each  urination  which  occurs  at  intervals  of  four  to  five  hours. 
Sounds  meet  an  obstruction  in  the  membranous  urethra,  but  a  filiform 
passes  with  ease,  and  a  dilating  follower.  No.  29-P.,  passes  into  the 
bladder.  (In  this  case  rupture  of  the  urethra  was  produced  at  operation 
by  an  orderly  who  was  holding  the  urethral  staff.) 

March  3,  1906. — Patient  voids  with  a  better  stream  and  the  fistula  is 
much  smaller.     There  is  still  slight  dribbling  after  urination. 

May  14,  1906. — The  fistula  is  almost  closed,  only  a  few  drops  of  urine 
escape.    There  is  no  incontinence,  but  the  end  of  urination  is  accompanied . 
by  a  slight  dribbling. 

May  17,  1906. — ^There  is  a  pin  point  fistula  in  the  perineum.  Only  a  few 
drops  of  urine  escape  through  it  and  the  patient  voids  twice  at  night  and 


420 


Rugli  H.  Young. 


at  intervals  of  four  hours  during  the  day.  Has  no  incontinence  of  urine 
at  night,  but  during  the  day  occasionally,  while  walking,  there  is  a  slight 
involuntary  escape  of  urine,  hut  this  is  improving. 

Exaviination. — 'Silver  catheter  passed  with  ease.    There  is  a  slight  hitch 
at  the  membranous  urethra,  but  after  manipulation  the  catheter  passes 


Fig.  51. — Large  median  and  lateral  lobes.     Case  122. 


with  ease  and  withdraws  25  cc.  residual  urine,  bladder  capacity  450  cc. 
Voided  urine  is  almost  clear  and  contains  microscopically  only  a  few 
pus  cells  and  bacilli. 

June  16,  1906. — Patient  returns  for  examination.  He  says  that  the  in- 
continence has  ceased.  He  is  able  to  retain  urine  for  three  or  four  hours, 
and  the  perineal  fistula  is  now  very  small.    His  condition  is  excellent. 


study  of  Ho  Cases  of  Perineal  Prostatectomy.  421 

September  18,  1906. — Ttie  patient  voids  urine  naturally,  five  times  dur- 
ing the  day  and  twice  at  night,  about  half  a  pint  at  a  time,  no  pain,  no 
erections.  There  is  a  pin-point  perineal  fistula  through  which  a  few  drops  of 
urine  escape  during  urination.  A  catheter  passes  but  detects  a  stricture 
of  large  caliber  at  the  membranous  urethra.  There  is  no  residual  urine 
present.  The  stricture  is  dilated  up  to  35-F.  with  the  Kollmann  dilator, 
and  the  fistula  partially  excised  and  curetted. 

Pathological  report. — The  specimen,  G.  U.  222,  consists  of  the  three  lobes 
of  the  prostate  which  have  been  removed  in  four  pieces  and  weighs  about 
90  gm.  The  left  lobe  is  a  globular  mass  measuring  5x3.5x3  cm.;  it  is 
smooth  ^  and  encapsulated,  and  on  section  shows  many  dilated  ducts  and 
considerable  stroma.  The  right  lateral  lobe  is  in  two  pieces  forming  a 
mass  about  as  large  as  the  left  and  similar  in  character.  A  piece  of  the 
lateral  wall  of  the  urethra  is  attached  to  one  of  the  pieces.  The  middle 
lobe  is  a  rounded  mass,  4.5  x  3.5  x  3  cm.  in  size,  fairly  smooth,  and  on  sec- 
tion shows  more  gland  tissue  and  less  stroma  than  the  lateral  lobes.  No 
ejaculatory  ducts  removed.  An  oxalate  calculus  about  2  cm.  in  diameter 
with  a  very  nodular  surface  was  removed. 

Microscopic  exainination. — ^The  hypertrophy  is  a  lobulated  glandular  one. 
The  acini  are  dilated,  with  many  areas  of  cystic  degeneration.  There  is 
considerable  endoglandular  proliferation  and  degeneration  of  the  epithe- 
lial cells.  The  stroma  is  rather  dense,  is  mostly  composed  of  fibrous  tissue, 
and  there  is  present  some  inflammatory  infiltration.  The  arteries  show  a 
moderate  degree  of  arteriosclerosis. 

Case  123. — Moderate  enlargement  of  median  and  lateral  lobes.  Residimm 
325  cc.    Cure.    Followed  five  months. 

No.  1121.    A.  W.  F.,  age  57,  married,  admitted  December  19,  1905. 

Complaint. — "  Frequency  and  difficulty  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  three  years  ago  with  hesitation  and  slight  diffi- 
culty in  urination.  Since  then  there  has  been  a  gradual  increase  in  the 
difficulty  and  frequency  of  urination,  but  he  has  had  no  pain  except  when 
the  bladder  becomes  full.  No  hematuria.  His  general  health  has  re- 
mained good. 

S.  P. — Urination  two  or  three  times  at  night.  Micturition  difficult,  slow, 
stream  small,  painless.     Sexual  powers  normal. 

Rectal. — The  prostate  is  moderately  enlarged,  bulging  towards  the  rec- 
tum, rounded,  smooth,  very  soft,  not  tender.  The  seminal  vesicles  are 
palpable  and  not  indurated.  Prostatic  secretion  contains  a  few  pus  cells, 
lecithin,  and  a  few  granule  cells. 

Urinalysis. — Slightly  cloudy,  acid,  1012,  no  albumin,  no  sugar,  pus  cells, 
a  few  epithelial  cells,  many  micrococci. 

Cystoscopic. — A  catheter  passes  with  ease  and  finds  325  cc.  residual 
urine.  The  bladder  capacity  is  large.  The  cystoscope  shows  a  very  small 
rounded,  slightly  elevated  median  lobe  with  very  small  sulci  on  either  side. 
The  lateral  lobes  are  only  slightly  enlarged  intravesically.     The  bladder 


433  Hugh  H.  Young. 

is  trabeculated  and  there  are  numerous  pouches  and  cellules,  but  no  defi- 
nite diverticula.  The  vesical  mucosa  is  only  slightly  inflamed.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  is  easily  felt,  and 
the  median  portion  of  the  prostate  shows  a  slight  but  definite  enlarge- 
ment. 

Preliminary  treatment. — Catheterization  two  or  three  times  daily,  uro- 
tropin,  hydrotherapy. 

Operation,  December  21,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  quite  adherent  to  the  capsule 
and  urethra,  and  in  removing  the  deeper  portions  it  was  necessary  to  em- 
ploy the  sharp  periosteal  elevator.  A  portion  of  the  median  bar  was  re- 
moved in  one  piece  with  the  right  lateral  lobe.  The  tractor  was  then 
removed  and  the  finger  inserted  in  the  urethra,  and  showed  a  circular 
constriction  of  the  prostatic  orifice  which  was  difficult  to  dilate  with  the 
finger.  Examination  showed  very  little  remaining  prostatic  tissue  in  the 
median  portion,  so  that  it  was  not  thought  necessary  to  remove  anything 
further.  The  wound  was  closed  as  usual  with  double  tube  drainage  and 
light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well. 
No  infusion  was  given.  Continuous  irrigation  was  given  on  return  to  the 
ward. 

Convalescence. — The  patient  reacted  well.  The  tubes  and  gauze  were 
removed  on  the  day  after  the  operation,  and  he  Avas  out  of  bed  the  next 
day.  Urine  came  through  the  penis  on  the  fourth  day,  interval  urination 
was  established  within  a  week,  the  fistula  closed  on  the  14th  day,  and  he 
was  discharged  on  the  22d  day  after  the  operation,  voiding  urine  at  inter- 
vals of  four  to  six  hours  with  perfect  control  and  the  perineal  wound 
healed. 

May  26,  1906. — <The  patient  returns  for  examination.  He  voids  naturally 
in  a  large  stream  four  or  five  times  during  the  day  and  not  at  all  during 
the  night,  about  one  pint  at  a  time.  He  suffers  no  pain.  Intercourse  is 
entirely  normal.  He  has  had  no  complications  and  no  treatment.  His  gen- 
eral health  is  good  and  he  has  gained  10  pounds  in  weight.  The  urine  is 
clear,  acid,  1006,  no  albumin,  microscopically  negative. 

September  14,  1906. — Letter.  The  fistula  closed  10  days  after  the  opera- 
tion and  has  not  been  open  since.  I  void  naturally  four  or  five  times  a 
day,  sometimes  not  at  all  at  night,  about  one  pint  at  a  time.  No  pain.  I 
am  cured. 

Pathological  report. — ^The  specimen,  G.  U.  221,  consists  of  three  pieces 
of  tissue.  The  left  lobe  comprises  two  of  these  pieces,  one  of  which  is  a 
small  lobule  about  1  cm.  in  diameter,  and  the  other  mass  3x2x1  cm. 
On  section  the  tissue  is  comprised  of  lobules  which  seem  rather  fibrous 
in  character,  although  areas  apparently  glandular  and  with  dilated  acini 
are  noted.  The  right  lateral  lobe  is  a  mass  3x2x1  cm.  It  is  firm  and 
elastic  in  consistence,  and  on  its  cut  surface  several  spheroidal  lobules 
are  seen.     The  total  weight  is  about  12  grams. 

Microscopic   exawAnation. — The   hypertrophy   tends   towards   the   fibro- 


study  of  IJ^o  Cases  of  Perineal  Prostatectomy.  423 

muscular  type,  alttiougli  in  seme  areas  the  gland  tissue  is  fairly  abundant. 
The  acini  in  these  areas  show  the  usual  typical  picture.  The  stroma  is 
largely  composed  of  fibrous  tissue,  there  being  present  practically  no 
muscle.  Some  areas  of  prostatitis  are  present.  The  arteries  show  a  mod- 
erate degree  of  arteriosclerosis. 

Case  124. — Moderate  hypertrophy  median  and  lateral  loies.  Induration 
suggesting  malignancy.     Cured. 

No.  1332.     J.  J.  J.,  age  58,  married,  admitted  December  17,  1905. 

Complaint. — "  Inability  to  pass  urine." 

No  history  of  gonorrhcea. 

Present  illness  began  about  15  years  ago  with  slight  difficulty  and  fre- 
quency of  urination  which  gradually  increased.  Ten  years  ago  he  was 
getting  up  four  times  at  night,  and  during  the  last  year  from  eight  to 
twelve  times  at  night  to  urinate,  and  he  had  considerable  difficulty,  pain 
and  straining  on  urination.  Two  weeks  ago  he  had  complete  retention 
of  urine  for  the  first  time  and  was  catheterized,  and  since  then  he  has 
been  using  the  catheter  himself,  being  unable  to  void  urine  naturally.  His 
symptoms  have  gotten  steadily  worse,  and  he  suffers  considerable  pain. 
No  history  of  hematuria,  calculus  or  pain  in  other  regions. 

Sexual  powers. — Absent. 

Examination. — The  patient  is  fairly  well  nourished.  His  pulse  is  full, 
bounding,  regular,  92,  no  arterioosclerosis.  The  heart  and  lungs  are  nega- 
tive. There  is  considerable  tenderness  over  the  region  of  the  bladder,  but 
the  abdomen  is  otherwise  negative. 

Rectal. — The  prostate  is  considerably  enlarged,  globular  in  shape  and 
about  the  size  of  a  small  orange.  It  is  elastic,  but  slightly  harder  than 
usual,  but  the  seminal  vesicles  are  negative  and  there  is  no  intervesicular 
mass.  The  surface  is  slightly  irregular,  but  there  are  no  enlarged  glands, 
the  rectal  wall  is  not  adherent  and  no  evidence  of  malignancy. 

Cystoscopic. — The  patient  has  a  retained  catheter,  retention  of  urine  be- 
ing complete.  The  bladder  has  become  contracted  and  holds  only  180  cc. 
on  forced  distention.  The  cystoscope  shows  a  sessile  rounded  median  lobe 
with  a  fairly  deep  sulcus  on  each  side.  Both  lateral  lobes  are  enlarged, 
and  there  is  a  fairly  deep  sulcus  in  front.  Numerous  mucous  polyps  are 
seen  attached  to  the  prostatic  lobes  in  various  places,  and  on  the  summit 
of  the  left  lateral  lobe  is  a  peculiar  sharp  pointed  peak. 

Preliminary  treatment. — Continuous  catheterization  for  10  days.  Hy- 
drotherapy and  urotropin.  On  the  evening  after  admission  the  patient 
had  a  chill  and  the  temperature  rose  to  104.6°.  For  the  next  five  days 
the  temperature  ranged  between  101°  and  103°.  After  that  it  was  prac- 
tically normal.     About  3000  cc.  of  urine  was  voided  daily. 

Urinalysis. — Cloudy,  1008,  faintly  acid,  no  albumin,  no  sugar.  Red  and 
white  blood  corpuscles. 

Operation,  December  28,  1905. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.     The  lateral  lobes  were  quite  adherent  to  the  prostate 


434  HugTi  H.  Young. 

and  quite  difficult  to  enucleate.  Examination  of  the  specimens  showed 
considerable  induration  in  spots  and  the  posterior  portion  of  the  right 
lobe  suggested  malignancy.  Frozen  sections  were  therefore  made,  but 
microscopic  examination  showed  the  area  to  be  composed  almost  entirely 
of  fibrous  tissue.  A  moderately  enlarged  median  lobe  was  removed  in  one 
piece  with  the  left  lobe,  a  tear  being  made  in  the  urethra,  but  no  mucous 
membrane  was  removed  and  the  ejaculatory  ducts  were  preserved.  The 
wound  was  closed  as  usual  with  double  catheter  drainage,  and  light  packs 
for  the  lateral  cavities.  He  was  infused  on  the  table  and  stood  the  opera- 
tion well,  pulse  at  the  end  being  90.  Continuous  irrigation  on  return  to 
the  ward. 

Convalescence. — The  patient  reacted  well,  the  highest  temperature  being 
100.2°  on  the  day  after  the  operation.  The  gauze  and  tubes  were  removed 
24  hours  after  the  operation  and  the  patient  was  up  in  a  chair  on  the 
third  day.  On  the  12th  day  the  patient  complained  of  slight  pain  in  the 
right  leg  which  was  found  to  be  somewhat  cedematous.  Examination 
showed  no  phlebitis,  and  the  swelling  soon  disappeared.  He  was  dis- 
charged on  the  22d  day  in  good  condition,  most  of  the  urine  passing 
through  the  urethra,  a  small  perineal  fistula  still  present.  The  perineal 
fistula  finally  closed. 

March  6,  1906. — ^Letter.  The  wound  has  remained  healed.  I  void  urine 
naturally  three  or  four  times  during  the  day  and  once  or  twice  during 
the  night,  about  one-third  of  a  pint  at  a  time.  I  suffer  a  slight  pain  after 
urination,  but  my  general  health  is  good,  and  I  have  gained  in  weight. 

May  12,  1906. — Letter.  The  wound  has  remained  healed,  and  I  am 
cured.  I  void  urine  naturally  three  or  four  times  during  the  day  and 
once  at  night,  about  a  pint  at  a  time.  I  suffer  no  pain.  Have  not  had 
erections  or  intercourse.    My  general  health  is  good. 

Septem'ber  18,  1906. — Letter.  I  void  urine  naturally  three  times  during 
the  day  and  once  at  night,  and  without  pain.  Sexual  intercourse  is  not 
entirely  satisfactory.     I  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  223,  consists  of  three  pieces 
of  tissue  representing  the  two  lateral  and  the  median  lobes.  The  lateral 
lobes  are  of  about  equal  size  and  weigh  about  10  gm.  The  median  lobe 
weighs  about  7  gm.  The  ejaculatory  ducts  have  not  been  removed.  No 
calculus.  The  tissue  is  composed  of  a  number  of  spheroids  of  varying 
size,  consistency  soft  and  homogeneous. 

Microscopic  examination. — tThe  hypertrophy  is  a  lobulated  moderately 
glandular  one.  Certain  lobules  show  complexity  of  outline.  The  stroma 
is  rather  small  in  amount.  In  other  lobules  the  acini  are  small,  separated 
by  broad  bands  of  stroma,  with  evidence  of  considerable  fibrous  tissue 
hyperplasia.  The  new  fibrous  tissue  is  arranged  concentrically  about 
small  oftentimes  atrophied  acini,  and  there  is  a  considerable  interstitial 
inflammatory  infiltration.  The  stroma,  as  a  whole,  contains  considerably 
more  connective  tissue  than  muscle.  The  arteries  show  a  moderate  de- 
gree of  arteriosclerosis. 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  425 

Case  125. — Yery  little  enlargement  of  lateral  lodes.  Small  pedunculated 
median  loie.    Complete  retention.    Cure.    Followed  five  mo7iths. 

No.  1138.     V.  J.  B.,  age  77,  widowed,  admitted  Dec.  31,  1905. 

Complaint. — "  Complete  retention  of  urine." 

Gonorrhoea  at  tlie  age  of  18. 

Present  illness  began  four  years  ago  with  frequency  of  urination,  which 
gradiTally  increased.  About  six  months  ago  he  began  to  suffer  pain  at 
the  beginning  of  urination.  It  was  generally  located  in  the  neck  of  the 
bladder  and  radiated  to  the  head  of  the  penis,  and  at  times  in  the  right 
back.  Of  late  urination  has  been  very  frequent,  and  pain  severe.  One 
week  ago  complete  retention  of  urine  came  on  and  since  then  the  patient 
has  been  catheterized  three  or  four  times  daily. 

Sexual  powers. — ^No  note  made.  General  condition  fairly  good,  but  weak. 
Three  years  ago  he  had  pain  in  the  region  of  the  right  kidney,  radiating 
to  the  testicle,  and  occasionally  blood  in  the  urine,  but  never  passed  a 
calculus. 

Examination. — ^The  patient  is  very  thin,  but  his  color  is  good. 

Chest. — ^The  percussion  note  is  slightly  hyperresonant,  and  on  ausculta- 
tion sounds  harsh.  Expiration  is  prolonged  and  an  occasional  dry  rale  is 
heard.     The  heart  and  abdomen  are  negative. 

Genitalia. — Negative. 

Rectal. — The  prostate  is  very  little  larger  than  normal,  firm,  but  not 
of  stony  hardness,  and  somewhat  tender.  The  lateral  lobes  project  up- 
ward more  than  normal,  but  the  region  of  the  seminal  vesicles  is  nega- 
tive. There  are  no  enlarged  glands  to  be  felt.  A  slight  rectal  stricture  is 
present,  and  a  depression  is  felt  on  the  left  side,  the  site  of  an  old  iistula. 

Urethral. — Catheterization  is  diflacult.  The  operator  failed  with  a  small 
coude  catheter,  silver  catheter  and  a  straight  rubber  catheter,  but  was 
finally  able  to  pass  a  rubber  catheter  threaded  upon  a  stilet  with  a  Be- 
nique.  About  one  pint  of  urine  evacuated.  The  stilet  was  then  withdrawn 
and  the  rubber  catheter  fastened  in  place  with  adhesive  plaster. 

Preliminary  treatment. ^-Continuous  drainage  through  a  retained  cath- 
eter, urotropin,  water  in  abundance.  In  order  to  prevent  contracture  of 
the  bladder,  the  end  of  the  catheter  was  kept  plugged  and  the  urine  evacu- 
ated when  the  bladder  became  full. 

Cystoscopic,  January  4,  1906. — The  cystoscope  shows  a  very  small 
rounded  median  lobe  with  a  shallow  sulcus  on  each  side.  The  lateral 
lobes  are  very  little  enlarged  intravesically,  and  there  is  no  sulcus  be- 
tween them  in  front.  The  bladder  is  markedly  trabeculated  with  numer- 
ous large  pouches,  but  no  diverticula.     There  is  no  calculus  present. 

Urinalysis. — Cloudy,  acid,  1009,  no  sugar,  albumin  a  trace.  Total  urine 
2200  cc.  Total  urea  19  gm.  Microscopically,  pus,  few  epithelial  cells,  no 
casts. 

Operation,  January  8,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  After  exposure  of  the  posterior  surface  the  prostate  did  not 
seem  at  all  enlarged.     The  lateral  lobes  were  easily  enucleated,  but  were 


426  Hugh  H.  Young. 

no  larger  than  normal  (Pig.  52).  A  small  mass  of  tissue  from  the  median 
portion  of  the  prostate  was  removed  through  one  of  the  lateral  cavities 
with  the  aid  of  the  tractor.  After  removal  of  the  instrument  the  finger 
was  inserted  and  a  small  pedunculated  median  lobe  discovered.  It  was  im- 
possible to  push  it  into  one  of  the  lateral  cavities,  but  it  was  easily  en- 
gaged by  forceps  passed  down  the  urethra  by  the  side  of  the  finger.  It 
was  then  drawn  into  the  urethra  and  excised  with  scissors,  the  mucous 
membrane  covering  it  being  removed  at  the  same  time.  Examination 
showed  no  further  obstruction  present,  and  the  wound  was  closed  as  usual 
with  double  tube  drainage  and  light  packs  for  the  lateral  cavities.  Infu- 
sion on  the  table,  continuous  irrigation  on  return  to  ward.  Patient  stood 
the  operation  well.    Pulse  at  end  115. 

Convalescence. — The  patient  reacted  well.     For  three   days  he  had  a 
temperature  between  99°  and  100°,  but  after  that  it  was  practically  nor- 


# 


Fig.  52. — Very  small  median  and  lateral  lobes,  causing  complete  retention 
of  urine.    Natural  size. 

mal.  The  irrigation  was  discontinued  at  the  end  of  24  hours,  the  gauze 
was  removed  at  the  end  of  32  hours,  and  the  drainage  tubes  at  the  end  of 
48  hours.  Urine  began  to  flow  through  the  anterior  urethra  on  the  11th 
day,  and  on  the  18th  day  was  able  to  retain  urine  for  three  hours  and  had 
perfect  control.  The  patient  was  walking  about  the  ward  on  the  seventh 
day,  but  the  perineal  fistula,  although  very  small,  was  slow  in  closing, 
but  was  apparently  closed  on  the  32d  day  when  the  patient  was  discharged. 
His  condition  was  excellent.  The  urinary  stream  good,  interval  from  two 
to  five  hours. 

February  13,  1906. — A  small  pin-head  fistula  persists.  A  catheter  passes 
with  ease  and  finds  25  cc.  residual  urine  and  a  bladder  capacity  350  cc. 

March  8,  1906. — A  few  drops  of  urine  still  escape  through  a  very  fine 
fistula  during  urination.  It  has  been  curetted,  and  treated  with  nitrate  of 
silver  several  times.  A  catheter  finds  no  residual  urine.  Bladder  ca- 
pacity 380  cc,  and  a  No.  28  sound  passes  with  ease. 

April  7,  1906. — iThe  fistula  is  not  yet  closed.  It  is  curetted  with  a  gim- 
let curette,  and  the  urethra  is  dilated  to  35-F.  with  the  Kollmann  dilator. 


study  of  H5  Cases  of  Perineal  Prostatectomy.  427 

May  1,  1906. — The  patient  voids  urine  at  intervals  of  five  hours  without 
difficulty  or  pain.  A  silver  catheter  passes  with  ease  and  finds  10  cc.  re- 
sidual urine,  a  bladder  capacity  of  300  cc.     General  health  is  excellent. 

May  24,  1906.-^he  patient  returns  for  examination.  The  fistula  has 
been  closed  one  week,  he  voids  urine  naturally  at  intervals  of  three  to  four 
hours,  from  200  to  300  cc.  at  a  time.  He  suffers  no  pain,  has  no  inconti- 
nence, and  his  general  health  is  excellent.     He  considers  himself  cured. 

June  16,  IQOe.-^The  patient  is  able  to  retain  urine  for  four  hours  and  a 
half  and  voids  as  much  as  340  cc.  at  a  time.  His  general  condition  is  ex- 
cellent. 

September  12,  1906. — Letter.  I  void  urine  naturally  about  three  times 
during  the  day  and  two  or  three  times  at  night;  the  largest  amount  at 
one  time  is  250  cc.  I  do  not  have  erections.  My  general  health  is  im- 
proved and  I  consider  myself  cured. 

Pathological  report— The  specimen,  G.  U.  228,  consists  of  five  pieces. 
The  right  lateral  has  been  removed  in  one  piece  and  measures  1.3  x  1  x  1 
cm.  It  is  lobulated,  soft,  and  on  section  shows  considerable  gland  tissue 
with  definite  fibrous  stroma  and  no  dilated  ducts.  The  left  lobe  is  com- 
posed of  two  pieces,  the  smaller  lobule  has  a  smooth  surface  and  is  about 
the  size  of  a  pea,  and  the  larger  is  about  the  size  of  the  right  lobe.  On 
section  it  is  similar  to  the  right.  The  middle  lobe  consists  of  two  pieces, 
the  smaller  the  size  of  a  small  pea,  and  the  larger  about  the  size  of  a  bean, 
and  one  surface  is  covered  with  mucous  membrane.  This  formed  a  pe- 
dunculated lobe  which  was  removed  by  the  finger  through  the  urethra. 
The  entire  prostate  probably  does  not  weigh  more  than  10  gm.,  no  ducts, 

no  calculi. 

Microscopic  examination.— The  right  lobe  shows  a  rather  ade- 
nomatous tissue  with  a  lobular  arrangement.  The  acini  have  con- 
voluted walls,  and  the  stroma  contains  more  fibrous  than  muscle 
tissue.  Outside  of  the  glandular'  lobules  there  is  considerable 
stroma  with  acini  scattered  here  and  there  through  it.  The  left 
lateral  shows  more  cystic  dilatation  than  the  right,  and  contains 
probably  more  gland  tissue.  The  stroma  between  the  intra-  and  extra- 
lobular  acini  contains  a  rather  large  amount  of  fibrous  tissue.  Here  and 
there  about  acini  there  is  considerable  newly  formed  connective  tissue.  In 
the  middle  lobe  the  gland  tissue  is  comparatively  sparse,  while  the  muscle 
and  fibrous  tissue  of  the  stroma  is  present  in  varying  amounts  in  different 
areas.  About  nearly  all  of  the  acini  which  are  present,  is  a  well  marked 
prostatitis  with  proliferation  and  desquamation  of  the  lining  epithelium 
in  varying  amounts  in  different  acini.  The  infiltration  in  places  has  ex- 
tended well  out  into  the  interstitial  tissue  and  there  has  been  a  consider- 
able formation  of  new  connective  tissue.  In  these  fibrous  areas  merely 
vestiges  of  former  acini  are  to  be  seen. 

The  hypertrophy  in  this  case  is  of  a  rather  mixed  variety,  in  places 
the  stroma  being  in  excess  and  in  others  the  adenomatous  tissue.  The 
stroma  as  a  whole  contains  more  fibrous  tissue  than  muscle,  and  this  is 
especially  true  in  the  middle  lobe  where  almost  pure  fibrous  nodules  are 
present. 


428 


Hugh  H.  Young. 


Case  126. — Moderate  enlargertient  of  lateral  lobes,  in  front  of  urethra. 
Residuum  940  cc.    Cure.    Followed  four  months. 

No.  1123.    A.  H.  S.,  age  65,  married,  admitted  December  19,  1905. 

Coviplaint. — "  Frequency  of  urination  and  pain  in  the  lower  abdomen." 

No  history  of  gonorrhoea. 

Present  illness  began  six  years  ago  with  difficulty  and  increased  fre- 
quency of  urination.  The  progress  of  the  case  was  very  slow  and  three 
years  ago  he  began  to  suffer  pain  in  the  lower  abdomen  when  the  bladder 
became  full.  Five  months  ago  he  had  an  attack  characterized  by  great 
pain  in  the  bladder,  straining  on  urination  at  intervals  of  from  one  to 
two  hours.  Complete  retention  of  urine  came  on  for  the  first  time  three 
months  ago,  and  one  quart  of  residual  urine  was  withdrawn.     Since  then 


Fig.  53.— Case  126. 


catheterization  has  not  been  required.  Urination  every  hour  during  the 
day,  three  or  four  times  at  night.  Pain  generally  present  in  the  lower  ab- 
domen. None  in  urethra,  perineum  or  back.  Occasional  dribbling  at  the 
end  of  urination.  He  has  not  lost  weight.  Sexual  powers  have  remained 
fairly  normal.     Erections,  coitus  and  ejaculations  about  normal. 

Examination. — The  patient  is  sparely  built,  but  apparently  sturdy,  lips 
are  of  good  color.  The  arteries  are  only  slightly  thickened,  and  the  pulse 
is  regular  and  of  good  volume. 

Chest. — No  note. 

Abdomen. — The  lower  abdomen  is  distended  and  on  percussion,  an  over- 
distended  bladder  reaching  the  umbilicus  is  felt.    Genitalia  negative. 

Rectal.— The  posterior  surface  of  the  prostate  feels  no  larger  than  nor- 
mal, and  is  about  normal  in  shape,  regular,  smooth,  firmer  than  normal, 
but  not  markedly  indurated.    The  seminal  vesicles  and  vasa  deferentia  are 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  429 

palpable  but  not  indurated.  Several  small  shotlike  masses,  either  phle- 
boliths  or  glands,  are  found  external  to  the  left  seminal  vesicle  and  one 
external  to  the  right  vesicle.  Above  the  prostate  a  very  large  distended 
bladder  is  felt.  The  walls  are  soft,  and  there  is  no  intervesicular  mass 
of  induration. 

Urinalysis. — Cloudy,  acid,  1016,  no  albumin,  no  sugar,  no  casts,  small 
amount  of  pus  and  epithelia  and  numerous  short  bacilli. 

Cystoscopic. — A  silver  catheter  passes  with  ease  and  finds  940  cc.  resid- 
ual urine.  The  bladder  is  very  large  and  the  tonicity  poor.  The  cystoscope 
shows  no  intravesical  enlargement  of  the  lateral  lobes  and  a  very  slight 
median  bar,  as  shown  in  the  accompaning  chart  (Fig.  53).  In  front  of 
the  median  bar  two  intraurethrally  projecting  lateral  lobes  are  seen,  and 
in  series  D,  with  the  beak  looking  downward  and  the  handle  depressed 
they  are  seen  to  almost  obscure  the  median  bar,  but  on  elevating  the  handle 
the  median  bar  comes  more  prominently  into  view  and  the  lateral  lobes 
become  separated.  In  series  U,  on  elevating  the  cystoscope  a  definite  in- 
traurethral  hypertrophy  of  the  right  lateral  lobe  is  seen.  The  pictures  in 
this  case  simulate  those  given  by  a  median  lobe,  but  careful  examination 
shows  that  the  rounded  mass  seen  in  3  and  4  was  an  intraurethral  lateral 
enlargement  rather  than  a  median.  The  bladder  is  greatly  trabeculated 
with  numerous  deep  pouches,  and  a  diverticulum  is  seen  near  the  vertex. 
The  ureters  cannot  be  made  out,  owing  to  pouches  and  trabeculation. 
There  is  quite  a  deep  pouch  behind  the  prostate,  but  it  can  be  thor- 
oughly explored,  showing  that  the  median  enlargement  is  very  slight. 
With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is  easily  felt 
and  a  small  but  definite  median  bar  is  made  out. 

Preliminary  treatment. — Catheterization  two  or  three  times  daily,  uro- 
tropin,  water  in  abundance.  On  January  2,  940  cc.  residual  urine  was  ob- 
tained, on  January  3,  600  cc,  and  on  January  4,  450  cc.  On  January  6  the 
residual  had  risen  to  660  cc.  and  the  patient  was  able  to  void  only  a 
small  amount  of  urine. 

Operation,  January  8,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  posterior  surface  of  the  prostate  was  no  larger  than  nor- 
mal, but  as  soon  as  the  bilateral  capsular  incisions  were  made,  the  edges 
of  the  wound  gaped  widely,  as  if  the  tissues  had  been  on  tension,  and 
two  large,  smooth  hypertrophied  lobules  appeared  in  the  bottom  of  the 
wound.  They  were  separated  from  the  posterior  portion  of  the  prostate 
by  fibrous  septum  and  were  themselves  thoroughly  encapsulated  and  easily 
enucleated  from  the  urethra  and  capsule  of  the  prostate,  were  spheroidal 
in  shape  and  measured  each  3x4x5  cm.  in  size.  They  lay  on  each  side  of 
the  urethra  which  was  considerably  flattened  by  them  and  projected  ante- 
riorly towards  the  symphysis  pubis  and  not  towards  the  bladder.  After 
removal  of  the  tractor  a  finger  was  inserted  through  the  urethra  into  the 
bladder,  the  prostatic  orifice  was  found  to  be  round  and  circularly  con- 
stricted so  that  it  had  to  be  dilated  to  admit  the  finger.  A  very  thin  me- 
dian bar  was  present,  not  sufficient  to  require  removal.  It  was  evident 
that  the  lateral  lobes  had  not  projected  towards  the  bladder.  The  opera- 
Vol.  XIV.— 28. 


430  Hugh  H.  Young. 

tive  findings  explain  why  the  prostate  seemed  very  little  enlarged  both 
on  rectal  and  cystoscopic  examination.  The  wound  was  closed  as  usual 
with  double  tube  drainage  and  light  pacte  for  the  lateral  cavities.  Con- 
tinuous irrigation  on  return  to  ward. 

Convalescence. — The  patient  reacted  well  from  the  operation.  The  tem- 
perature did  not  rise  above  100°.  The  irrigation  was  discontinued  after 
12  hours,  the  gauze  and  tubes  were  both  removed  in  24  hours  after  the 
operation,  and  almost  immediately  afterwards  urine  was  passed  at  inter- 
vals, and  without  incontinence  through  the  perineal  wound.  On  the  third 
day  the  bladder  became  distended  and  catheterization  was  necessary.  Af- 
ter that  he  was  able  to  void  at  increasingly  long  intervals,  but  the  urine 
did  not  come  through  the  urethra  until  the  12th  day.  The  fistula  closed 
on  the  16th  day.  The  patient  was  out  of  bed  on  the  4th  day,  began  to 
walk  on  the  6th  day,  and  had  no  complications.  He  left  the  hospital 
on  the  21st  day,  able  to  retain  urine  for  five  hours  with  no  incontinence, 
no  pain. 

February  3,  1906. — Urine  is  voided  freely,  sometimes  as  much  as  a  pint 
at  a  time,  at  intervals  of  four  or  five  hours.  The  perineal  wound  has  re- 
mained closed.  The  urine  is  only  slightly  cloudy,  but  contains  pus  and 
bacteria. 

May  15,  1906. — Patient  returns  for  examination.  He  says  he  voids  urine 
normally,  does  not  get  up  at  night  to  urinate.  He  has  no  pain  except  oc- 
casionally a  slight  pain  in  the  back.  He  passes  about  one  pint  of  urine 
at  a  time.  His  general  health  is  excellent.  He  has  gained  13  pounds  and 
considers  himself  cured. 

Examination. — Patient  looks  well.  There  are  small  shotlike  glands  in 
both  groins.     The  urine  is  cloudy  and  contains  pus  and  bacilli. 

Rectal. — In  the  region  of  the  prostate  a  slightly  indurated  mass  smaller 
than  the  normal  prostate  is  felt.  It  is  smooth,  elastic,  there  are  no  nod- 
ules. There  is  slight  induration  in  the  region  of  both  seminal  vesicles 
and  a  few  slightly  indurated  cords  are  to  be  felt  on  each  side.  Along 
the  pelvic  wall  on  the  left  side  one  gland  about  1  cm.  in  diameter,  but  fairly 
soft,  is  felt.  Several  small  shotty  bodies  are  felt  along  the  rectal  wall. 
A  catheter  passes  easy  and  withdraws  150  cc.  of  urine.  The  patient  did 
not  think  he  had  been  able  to  empty  his  bladder  as  completely  as  usual. 

September  IJf,  1906. — Letter.  Urine  is  voided  naturally  eight  times  dur- 
ing the  day  and  once  at  night,  sometimes  not  at  all,  about  one  pint  at  a 
time.  No  pain.  Intercourse  is  not  as  satisfactory  as  before  operation. 
My  general  health  is  good.     I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  226,  consists  of  three  pieces, 
the  left  lateral,  the  right  lateral  and  the  middle  lobes,  each  in  one  piece.  A 
fourth  piece  of  tissue  which  consisted  of  a  portion  of  the  prostatic  cap- 
sule and  the  adjacent  tissue  is  also  preserved.  The  entire  weight  of  the 
prostate  is  not  great.  The  left  lateral:  4x3x2.5  cm.,  lobulated,  soft.  On 
section  dense  bands  of  fibrous  tissue  are  seen  between  the  spheroids.  Di- 
lated acini  are  seen  in  the  larger  lobules.  Right  lateral  and  median:  The 
right  lateral  is  about  the  size  of  the  left  and  is  largely  composed  of  one 


study  of  145  Cases  of  Perineal  Prostatectomy.  431 

spheroidal  lobule;  at  one  end,  however,  numerous  smaller  lobules  are 
seen,  and  here  numerous  small  hemorrhagic  points  are  present.  The  mid- 
dle lobe  is  about  one-third  the  size  of  the  lateral  and  much  firmer,  not 
lobulated,  and  the  cut  surface  is  composed  of  small  yellowish  areas  scat- 
tered in  a  fairly  dense  stroma.  Near  the  periphery  a  small,  round  nodule 
6  mm.  in  diameter,  yellowish  in  color,  firm  and  smooth  is  seen.  The  tissue 
removed  with  the  posterior  capsule  measured  2.5x2x1  cm.,  is  firm  and 
contains  some  dilated  ducts  and  small  hemorrhagic  points. 

Microscopic  examination. — ^The  hypertrophy  is  a  moderately  glandular 
one,  areas  fairly  rich  in  glandular  acini  alternating  with  areas  in  which 
the  stroma  is  very  much  in  excess.  The  acini  are  dilated,  and  the  lumina, 
as  a  rule,  show  rather  marked  endoglandular  proliferation,  the  epithelium 
often  being  many  layers  thick.  The  stroma  as  a  whole  is  quite  dense,  and 
contains  a  moderate  amount  of  muscle.  There  are  numerous  areas  of 
prostatitis. 

In  the  middle  lobe  a  small  nodule  encapsulated  and  of  a  bright  yellow 
color  was  noted  in  the  fresh  specimen.  Section  including  this  area  shows 
the  nodule  to  be  a  pure  adenoma.  It  is  composed  of  numerous  very  small 
alveoli  lined  by  a  single  layer  of  epithelium  resembling  somewhat  in 
character  that  of  a  mucous  gland.  The  lumen  is  small,  the  epithelium  rests 
on  a  basement  membrane,  and  the  nuclei  are  at  the  basal  end.  Interlacing 
between  the  various  acini  is  a  rather  slender  loose  connective  tissue  stroma. 
The  nodule  does  not  resemble  in  character  at  all  the  usual  adenomatous 
areas  which  one  sees  in  the  prostate.  Towards  the  periphery  of  this  lob- 
ule the  acini  are  compressed. 

Case  127. — Slight  enlargement  of  lateral  lobes.  Small  pedunculated 
median  lobe.  Catheterism.  Complication,  epididymitis.  Cure.  Followed 
five  months. 

No.  1139.  A.  R.  W.,  age  65,  married,  admitted  January  9,  1906. 

Complaint. — "  Frequency  and  difiiculty  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  five  years  ago  with  slight  difficulty  and  frequency 
of  urination.  After  that  there  was  a  gradual  increase  in  the  difiiculty, 
but  not  in  frequency  until  six  months  ago  when  an  attack  of  very  frequent 
urination  came  on  and  was  associated  with  pain  in  the  bladder  and  ure- 
thra, after  two  days  he  was  again  comfortable  until  three  months  ago, 
since  when  urination  has  been  difllcult,  painful  and  very  frequent.  Re- 
tention of  urine  has  never  been  complete,  but  for  the  past  10  days'  cath- 
eterization has  been  performed  once  or  twice  daily,  and  considerable  re- 
lief afforded. 

S.  P. — The  patient  voids  urine  every  hour  until  catheterized,  and  after 
that  not  until  eight  hours  have  elapsed.  There  is  only  slight  pain  in  the 
bladder,  which  is  relieved  by  voiding.  His  sexual  powers  are  normal. 
General  health  excellent. 

Examination. — The  patient  is  a  sparsely  built  man,  but  the  lips  are  of 
good  color  and  there  is  no  arteriosclerosis.     Genitalia  negative. 


432 


Hugh  H.  Young. 


Rectal. — The  prostate  is  only  moderately  enlarged,  rounded,  slightly  ir- 
regular, surface  firmer  than  normal,  hut  not  markedly  indurated.  The 
seminal  vesicles  are  negative,  and  there  is  no  intervesicular  mass,  no 
tenderness,  no  glands,  rectal  mucosa  not  adherent.  The  prostatic  secre- 
tion contains  a  great  many  pus  cells,  a  small  number  of  lecithins,  numer- 
ous actively  motile  spermatozoa. 

Cystoscopic. — A  catheter  passes  with  ease.  The  bladder  capacity  is 
large,  retention  of  urine  is  complete.  The  cystoscope  shows  a  small  glob- 
ular median  lobe  with  a  fairly  deep  sulcus  en  each  side,  as  shown  in  the 
accompanying  chart  (Fig.  54).  By  deflecting  the  handle  to  the  left  and 
depressing  it  Series  U  is  obtained.  In  1  the  anterior  margin  of  the  pros- 
tate alone  is  seen.    By  gradually  elevating  the  handle  the  side  of  the  mid- 


FiG.  54.— Case  127. 


die  lobe  comes  into  view  in  2  and  becomes  more  and  more  prominent  in 
3  and  4.  By  carrying  the  handle  to  the  right  and  going  through  the  same 
procedures.  Series  U'  is  obtained,  the  cystoscope  descending  into  the  sul- 
cus to  the  left  of  the  middle  lobe.  The  lateral  lobes  are  only  slightly  en- 
larged and  there  is  no  sulcus  between  them  in  front.  The  bladder  is  con- 
siderably trabeculated  and  there  is  a  very  large  pouch  behind  the  inter- 
ureteral  ligament  which  is  considerably  enlarged.  The  ureters  cannot  be 
made  out.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is 
easily  felt,  there  is  no  subtrigonal  thickeaing  and  only  moderate  increase 
in  the  median  portion  of  the  prostate. 

Urinalysis. — Cloudy,  1014,  albumin  in  small  amount,  no  sugar.  Micro- 
scopically pus  cells  in  considerable  number. 

Preliminary  treatment. — Urotropin,  water  in  abundance,  catheterization 
three  or  four  times  daily. 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  433 

Operation,  January  12,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  easily  enucleated,  each  in  one 
piece  and  were  only  moderately  enlarged.  The  median  bar  and  a  small 
sessile  median  lobe  with  a  portion  of  the  mucous  membrane  covering  it 
were  removed  in  one  piece  through  the  left  lateral  cavity.  Examination 
with  the  finger  showed  no  remaining  obstruction.  The  urethra  was  torn, 
and  possibly  the  ejaculatory  ducts,  but  no  portion  of  the  ducts  were  re- 
moved. The  wound  was  closed  as  usual  with  double  tube  drainage  and 
light  packs  for  the  lateral  cavities.  The  patient  stood  the  operation  well. 
Infusion  and  continuous  irrigation  on  return  to  room. 

Convalescence— The  patient  reacted  well.  Temperature  night  following 
99°,  pulse  90.  Continuous  irrigation  was  kept  up  for  24  hours.  The  tubes 
and  gauze  were  removed  on  the  day  after  the  operation.  The  patient  was 
out  of  bed  on  the  third  day  and  did  well  until  the  22d  day,  when  there  was 
a  rise  of  temperature  to  103.7°,  associated  with  epididymitis  on  the  right 
side.  For  a  week  there  was  a  nocturnal  rise  of  temperature  from  100° 
to  103°,  after  that  it  was  normal.  The  left  epididymis  also  became  swol- 
len. On  this  account  the  patient  did  not  leave  the  hospital  until  the  35th 
day.  The  perineal  fistula  closed  about  the  21st  day.  On  discharge  from 
the  hospital  on  the  35th  day,  the  wound  was  closed  and  the  patient  voided 
urine  at  intervals  of  from  one  to  two  hours.  The  sphincter  was  a  little 
weak,  but  there  was  no  definite  incontinence. 

March  8,  1906. — The  patient  complains  that  urination  is  still  frequent 
and  imperative.  If  he  attempts  to  hold  urine  too  long,  a  very  strong  de- 
sire to  void  comes  on,  and  he  is  unable  to  retain  it.  By  voiding  at  inter- 
vals of  from  one  to  two  hours  he  has  no  leakage. 

Examination. — The  wound  is  firmly  healed,  silver  catheter  passes  with 
ease,  there  is  no  stricture  present,  no  residual  urine,  the  bladder  is  irri- 
table and  contracted,  but  able  to  hold  250  cc.  on  forcible  distention.  The 
patient  is  instructed  to  retain  urine  as  long  as  possible  in  order  to  distend 
bladder. 

May  15,  1906. — Letter.  I  void  urine  naturally,  four  or  five  times  during 
the  day  and  usually  twice  at  night.  I  suffer  no  pain.  I  have  imperfect 
erections,  but  have  not  yet  attempted  intercourse.  My  general  health  is 
very  good.    I  have  gained  in  weight  and  I  consider  myself  cured. 

June  10,  1906. — Since  the  last  report  I  have  improved  and  "  the  power 
for  sexual  intercourse  has  been  well  nigh  fully  restored." 

Septem'ber  12,  1906. — Letter.  I  void  urine  perfectly,  four  times  during 
the  day  and  twice  at  night,  in  normal  amounts.  I  suffer  no  pain.  Sexual 
intercourse  is  satisfactory.     I  am  thoroughly  cured. 

Pathological  report. — The  specimen,  G.  U.  233,  consists  of  the  three  lobes 
of  the  prostate  removed  in  four  pieces,  and  weighs  about  25  gm.  The 
left  lobe  is  in  two  pieces,  the  larger  3  x  2.5  x  2  cm.,  lobulated,  soft,  on  sec- 
tion showing  spheroids,  moderate  amount  of  glandular  tissue  with  inter- 
vening stroma  and  one  retention  cyst  2  mm.  in  diameter.  A  few  small 
spheroids  are  apparently  entirely  fibrous.  The  small  piece  measures  1  x 
.5  x  .5  cm.     The  right  lobe  is  about  the  size  of  the  left,  is  lobulated,  soft. 


434  HugJi  H.  Young. 

and  similar  in  character  to  the  right,  except  that  there  are  no  fibrous  nod- 
ules, and  several  hemorrhagic  points  are  seen.  The  median  portion  of 
the  prostate  consists  of  a  pedunculated  lobe  about  1  cm.  in  diameter,  cov- 
ered with  mucous  membrane  and  perched  upon  a  distinct  median  bar 
2.5  X  1.5  X  1  cm.  in  size.  The  bar  is  quite  fibrous,  but  some  gland  tissue 
with  retention  cysts  is  present.  Several  seed  calculi  are  seen  in  the 
periphery  of  the  bar.  The  ejaculatory  ducts  were  not  removed.  No  vesi- 
cal calculus. 

Microscopic  examination  shows  a  very  glandular  tissue,  in  places  rather 
diffuse  and  in  others  arranged  in  lobules.  Many  of  the  acini  are  very  much 
dilated,  especially  in  the  lobulated  areas  with  a  very  small  amount  of 
stroma  interlacing  between  them.  The  lumina  of  the  culs-de-sac  are  ir- 
regular and  complex,  papillomatous  tufts  often  growing  out  into  the  lu- 
men. The  stroma  is  composed  of  muscle  and  connective  tissue  in  varying 
proportions.  In  areas  there  has  been  a  great  deal  of  connective  tissue 
hyperplasia  and  a  decrease  of  gland  tissue.  There  are  fairly  numerous 
areas  here  and  there  of  polynuclear  cell  infiltration. 

The  hypertrophy  is  for  the  most  part  a  glandular  one,  although  there 
are  a  considerable  number  of  areas  where  the  fibrous  tissue  is  in  excess. 

Case  128. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Catheter 
for  nine  years.    Cure.    No  complications.    Followed  four  months. 

No.  1179.    W.  T.,  age  SO,  married,  admitted  January  15,  1906. 

Complaint. — "  Prostatic  hypertrophy.     Catheterism." 

No  history  of  gonorrhoea. 

Present  illness  began  about  10  years  ago  with  sudden  complete  reten- 
tion of  urine,  requiring  catheterization.  Examination  at  that  time  showed 
an  enlarged  prostate,  alkaline,  purulent  urine.  Catheterization  was  neces- 
sary six  times,  but  at  the  end  of  three  weeks  the  patient  was  apparently 
well.  The  diagnosis  of  abscess  of  the  prostate  was  made.  One  year  later 
retention  of  urine  again,  and  since  then  occasional  catheterization  has 
been  necessary  and  at  times  he  has  suffered  considerably  from  prostatitis. 

/S.  P. — Voluntary  urination  is  possible,  but  difficult  and  frequent,  the 
intervals  being  about  two  hours.  The  catheter  is  used  once  or  twice  a 
day  and  generally  withdraws  10  or  12  ounces  of  urine.  Much  more  urine 
is  secreted  during  the  night  than  in  the  day.  Of  60  ounces  voided  daily 
often  50  is  secreted  during  the  night.  He  suffers  no  pain  during  or  after 
urination,  passed  no  calculi,  no  blood. 

Sexual  powers. — ^Erections  and  nocturnal  emissions  occasionally.  Sexual 
powers  fairly  normal  up  to  a  year  ago.     No  intercourse  since. 

Examination. — -The  patient  is  a  sturdy  looking  man  with  lips  of  good 
color.  Heart  and  lungs  negative.  Pulse  80,  regular,  no  arteriosclerosis. 
Abdomen  negative. 

Genitalia. — The  right  testicle  Is  atrophic,  epididymis  slightly  tender 
(epididymitis  three  years  ago).  There  is  a  small  incomplete  hernia  on 
the  left  side. 

Rectal. — The  prostate  is  considerably  enlarged  and  the  upper  end  can- 


study  of  145  Cases  of  Perineal  Prostatectomy.  435 

not  be  reached.  The  left  lobe  is  rounded,  smooth,  slightly  indurated,  but 
elastic  and  uniform  in  consistence.  In  the  anterior  portion  of  the  right 
lobe  is  a  prominent  rounded  mass  about  2  cm.  in  diameter  which  projects 
forward  and  outward  towards  the  triangular  ligament  and  the  consistence 
is  firmer  than  the  rest  of  the  prostate,  but  it  is  smooth,  and  is  not  adher- 
ent to  rectum  or  to  surrounding  structures.  The  rest  of  the  right  lobe  is 
similar  to  the  left.  The  seminal  vesicles  cannot  be  reached,  no  enlarged 
glands  are  felt. 

Urinalysis. — Cloudy,  neutral,  1024,  no  albumin,  no  sugar.  Microscopic- 
ally pus  cells  few,  no  bacteria. 

Cystoscopic. — A  small  coude  catheter  passes  with  ease.  There  is  no 
roughness  or  obstruction  in  the  anterior  portion  of  the  prostatic  urethra, 
and  only  25  cc.  residual  urine  is  found  (probably  an  error).  The  bladder 
capacity  is  250  cc.  The  cystoscope  shows  a  small  pedunculated  median 
lobe  with  a  deep  cleft  on  each  side.  The  lateral  lobes  are  not  very  large, 
but  form  a  definite  polyp  projecting  into  the  bladder.  There  is  no  sulcus 
between  them  in  front.  The  bladder  is  moderately  trabeculated,  slightly 
inflamed.  The  right  ureter  cannot  be  seen  for  the  median  lobe.  The  left 
ureter  appears  normal.  With  finger  in  rectum  and  cystoscope  in  urethra 
the  beak  cannot  be  felt  and  the  median  portion  of  the  prostate  is  consid- 
erably increased. 

Operation,  January  16,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  rectum  was  quite  adherent,  but  the  posterior  cap- 
sule of  the  prostate  was  smooth.  The  prominent  lobule  projecting  from 
the  anterior  portion  of  the  right  lobe  was  firm,  but  not  of  stony  hardness, 
and  did  not  suggest  malignancy,  but  nevertheless  it  was  thought  best  to 
remove  with  it  the  capsule  and  the  adjacent  urethra  without  cutting  into 
it.  The  lateral  lobes  were  easily  enucleated,  each  in  one  piece.  Most  of 
the  right  lateral  wall  of  the  urethra  was  removed,  but  the  floor  and  left 
lateral  wall  of  the  urethra  and  the  ejaculatory  ducts  were  preserved.  The 
median  lobe  was  removed  through  the  right  lateral  cavity  and  measured 
2x2x3  cm.  in  size.  Examination  with  the  finger  in  the  bladder  showed 
no  further  enlargement.  The  wound  was  closed,  as  usual,  with  double 
tube  drainage  and  light  packs  for  the  lateral  cavities.  Infusion  on  table, 
continuous  irrigation  on  return  to  ward.  The  patient  stood  the  operation 
well,  pulse  at  the  end  90. 

Convalescence. — Patient  reacted  well.  The  temperature  rising  only  to 
100.4°  on  the  night  after  the  operation  and  after  that  normal.  The  irriga- 
tion was  discontinued  after  12  hours,  the  gauze  removed  after  24  hours 
and  the  tubes  after  48  hours.  There  was  considerable  pain  and  nausea 
for  two  days.  The  patient  was  up  in  a  chair  on  the  fifth  day,  and  urine 
came  through  the  anterior  urethra  on  the  11th  day.  The  perineal  fistula 
closed  finally  on  the  17th  day,  and  the  patient  was  discharged  on  the  23d 
day.  At  that  time  he  had  no  incontinence,  but  a  few  drops  of  urine  occa- 
sionally escaped  if  he  coughed.  He  drank  much  water,  and  voided  about 
60  ounces  of  urine  during  the  night  at  intervals  of  an  hour.  During  the 
day  the  interval  was  about  three  hours,  and  the  total  amount  much  less 


•±36  Hugh  R.  Young. 

than  during  the  night.  The  stream  was  large,  painless,  but  there  was  a 
slight  spasmodic  contracture  at  the  end  of  urination.  The  wound  was 
firmly  closed  and  his  general  health  excellent. 

May  S,  1906. — Letter.  The  wound  has  remained  healed.  I  void  urine 
naturally,  with  perfect  ease  at  intervals  of  about  three  hours,  and  from 
four  to  six  ounces  at  a  time.  My  sphincter  is  still  a  little  weak,  especially 
when  I  try  to  hold  urine  longer  than  three  hours.  I  have  had  no  erections. 
My  general  health  is  good.  I  have  gained  seven  pounds  and  consider  my- 
self cured. 

September  15,  1906. — Letter  returned  with  a  report  that  patient  is  trav- 
eling in  Europe  and  that  he  is  perfectly  well. 

Pathological  report. — The  specimen,  G.  U.  234,  consists  of  the  three  lobes 
of  the  prostate  and  weighs  35  gm.  The  right  lobe  measures  6  x  3  x  2.5  cm. 
is  lobulated,  soft,  and  on  section  is  succulent  and  shows  fine  fibrous  bands 
between  glandular  lobules.  One  pin-point  abscess  is  seen.  The  middle 
lobe  is  composed  of  two  pieces,  the  larger  2  x  2.5  x  1.5  cm.  and  the  smaller 
1.5  X  1  X  1  cm.  The  general  appearance  is  the  same  as  that  of  the  right 
lobe,  except  that  a  few  dilated  acini  are  encountered.  The  left  lobe  is  com- 
posed of  two  pieces  about  equal  in  size.  One  is  similar  to  the  right  lobe, 
the  other  contains  a  peculiar  lobule  about  -he  size  of  a  beet,  golden  yellow 
in  color,  distinctly  encapsulated.  Surrounding  the  lobule  are  areas  of 
hemorrhage.  A  portion  of  the  right  lateral  wall  of  the  urethra  has  been 
removed.    The  ejaculatory  ducts  have  not  been  removed;  no  calculus. 

Microscopically  the  hypertrophy  is  mostly  composed  of  gland  tissue 
with  a  moderate  degree  of  dilatation  of  the  acini  and  cystic  degeneration. 
The  epithelium  lining  of  many  of  the  acini  shows  marked  invagination,  and 
is  of  the  usual  tall  columnar  type.  In  portions  of  the  hypertrophied  tissue 
there  is  a  marked  formation  of  inflammatory  tissue,  particula.rly  marked 
about  the  acini,  but  also  interlacing  to  a  considerable  extent  into  the  in- 
terstitial tissue.  In  portions  the  stroma  is  largely  muscle  fibers,  many  of 
which  are  concentrically  arranged  about  the  acini,  but  in  other  areas,  es- 
pecially those  showing  most  evidence  of  an  old  inflammatory  process,  the 
connective  tissue  predominates.  The  hypertrophy,  as  a  whole,  is  a  dis- 
tinctly adenomatous  one. 

Case  129. — Considerable  enlargement  of  median  and  lateral  lobes.  Cath- 
eterism  three  years.    Cured. 

No.  1182.     M.  H.,  age  55,  married,  admitted  January  24,  1906. 

Complaint. — ^'  Catheter  life." 

Gonorrhoea  at  age  of  18  and  22  years,  associated  with  epididymitis. 

Present  illness  began  four  years  ago  with  slight  frequency  of  urination 
and  discomfort.  Complete  retention  of  urine  came  on  about  one  year 
later,  was  followed  by  severe  cystitis.  Since  then  the  patient  has  cath- 
eterized  himself  at  least  once  daily  and  of  late  generally  four  times  a  day. 

S.  P. — The  patient  catheterizes  himself  four  times  a  day  and  can  void 
only  a  very  small  amount  of  urine  naturally.  He  has  never  suffered  pain 
nor  has  any  dribbling.    His  general  health  has  remained  good. 


study  of  145  Cases  of  Perineal  Prostatectomy.  437 

Sexual  powers  have  become  weakened  in  the  past  three  years,  but  erec- 
tions are  still  firm.     Coitus  now  about  once  a  month. 

Examination. — ^The  patient  is  well  nourished  with  lips  of  good  color. 
The  heart  and  lungs  are  negative.     Arteries  not  sclerotic. 

Genitalia. — In  both  groins  are  scars  of  former  suppurative  adenitis. 

Rectal. — ^The  prostate  is  considerably  enlarged,  especially  in  the  long 
diameter.  The  median  furrow  and  notch  being  obliterated  and  replaced 
by  a  rounded  mass.  The  general  contour  of  the  prostate  is  rounded, 
smooth,  soft,  there  are  no  areas  of  induration,  no  marked  tenderness.  The 
seminal  vesicles  are  negative  and  no  glands  are  to  be  felt.  Prostatic 
secretion  is  composed  largely  of  pus  cells,  spermatozoa  and  a  few  large 
granule  cells  present. 

Urinalysis. — Slightly  cloudy,  acid,  1022,  no  albumin,  no  sugar,  no  casts. 
Microscopically,  pus  cells  and  staphylococci. 

Gystoscopic. — A  large  coude  catheter  passes  with  ease  and  finds  260  cc. 
residual  urine.  The  bladder  is  contracted  and  on  forced  distension  holds 
only  280  cc.  The  cystoscope  shows  a  fairly  large  sessile  rounded  median 
lobe  with  a  deep  sulcus  on  each  side.  The  lateral  lobes  are  only  slightly 
intravesically  enlarged,  and  there  is  no  cleft  between  them  in  front.  The 
bladder  is  markedly  trabeculated  and  numerous  small  pouches  are  seen. 
There  are  no  diverticula  and  no  calculi  present.  The  ureters  are  con- 
cealed by  the  median  bar.  There  is  only  a  slight  cystitis.  With  finger  in 
rectum  and  cystoscope  in  urethra  it  is  impossible  to  feel  the  beak  of  the 
instrument,  owing  to  the  thickness  and  length  of  the  median  portion  of 
the  prostate. 

Operation,  January  21,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  moderately  large,  soft  and  easily 
enucleated.  The  median  lobe  was  pedunculated  and  about  4  cm.  in  diam- 
ter.  It  was  delivered  into  the  right  capsular  cavity  and  enucleated.  The 
urethra  and  ejaculatory  ducts  were  preserved.  The  wound  was  closed  as 
usual  with  double  catheter  and  gauze  drainage.  Patient  stood  the  opera- 
tion well,  pulse  at  the  end  being  95.  Infusion  and  continuous  irrigation 
on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  was  normal 
for  three  days  and  on  the  sixth  day  rose  to  104.5°,  but  rapidly  fell  to  nor- 
mal again.  There  was  a  small  stitch  abscess  on  one  side  of  the  wound 
and  an  abscess  in  one  of  the  glands  in  the  left  groin.  During  this  time 
the  patient  had  slight  fever,  never  over  102°,  and  after  the  18th  day  the 
temperature  was  normal.  The  gauze  was  removed  in  24  hours  and  the 
tubes  in  48  hours.  Patient  was  up  in  a  chair  on  the  third  day,  and  on  the 
fifth  day  urine  passed  through  the  anterior  urethra  in  a  large  stream,  and 
for  two  days  no  urine  escaped  through  the  perineum  and  patient  voided  at 
intervals  of  three  hours  with  perfect  control.  On  the  sixth  day  there  was 
a  firm  erection  of  the  penis.  On  the  sixth  day  a  small  stitch  abscess  was 
opened,  and  on  the  18th  day  a  small  suppurative  adentitis  in  the  left  groin 
was  incised.  The  perineal  fistula  healed  completely  on  the  24th  day  and 
the  patient  left  the  hospital  on  the  31st  day.    At  that  time  he  voided  urine 


438  Eugli  E.  Young. 

at  intervals  of  five  hours  and  with  perfect  control,  no  pain.  Urine  was 
clear  and  contained  no  bacteria.     The  general  condition  was  excellent. 

May  8,  1906. — Letter.  The  wound  has  remained  healed.  I  void  urine 
naturally  at  intervals  of  about  four  hours  during  the  day,  and  12  ounces 
at  a  time.  I  retire  at  11  p.  m.  and  arise  to  urinate  at  6  a.  m.  I  have  erec- 
tions and  satisfactory  sexual  intercourse,  the  only  difference  being  that 
the  amount  of  fluid  ejaculated  seems  less.  My  general  health  is  very  good 
and  T  consider  myself  perfectly  cured. 

September  15,  1906. — Letter.  I  void  urine  perfectly,  four  times  during 
the  day  and  often  not  at  all  at  night,  14  ounces  at  a  time.  I  have  no  pain. 
Sexual  intercourse  is  entirely  satisfactory.  Urine  is  clear  with  only  an 
occasional  shred  and  no  albumin.  I  am  entirely  cured.  (The  patient, 
who  is  a  physician,  remarks:  "  Yours  is  beyond  doubt  the  ideal  operation.") 

Case  130. — Moderate  hypertrophy  of  median  and  lateral  lobes  of  pros- 
tate. Catheter  ism.  Attacks  of  intense  pain  in  back  before  and  after  op- 
eration.   Perineal  prostatectomy.    Complete  relief  of  urinary  symptoms. 

S.     No.  18,721.     M.  L.  M.,  age  60,  married,  admitted  January  31,  1906. 

Complaint. — "  Prostatic  enlargement,  pain  in  the  back." 

Gonorrhoea  12  years  ago,  followed  by  stricture.  Six  years  ago  swelling 
of  testicle. 

Present  illness  began  six  years  ago  with  frequency  of  urination.  There 
was  also  considerable  difficulty  and  at  times  much  straining  required. 
Since  then  there  has  been  a  gradual  increase  in  the  difficulty,  but  during 
the  past  year  he  has  been  very  much  worse,  and  has  had  to  void  at  inter- 
vals of  from  one  and  one-half  to  two  hours  with  considerable  straining 
which  has  produced  hemorrhoids  and  pain  on  defacation.  For  the  past 
two  and  one-half  years  there  has  been  slight  dribbling  of  urination.  Two 
weeks  ago  urination  became  very  difficult  and  painful,  and  there  was  an 
intense  pain  in  the  back.  His  physician  catheterized  him  and  drew  off  a 
large  amount  of  urine,  and  since  then  the  catheter  has  been  passed  twice 
daily.  He  has  continued  to  suffer  severe  pain  constantly  in  his  back 
which  has  been  pronounced  lumbago.  Any  sudden  movement  produces  se- 
vere paroxysms  of  pain  in  the  lumbar  region.  He  has  had  no  paralysis  of 
any  sort,  but  the  pain  has  been  confined  to  the  back. 

Status  prcBsens. — Urination  very  difficult,  painful,  very  frequent.  Cath- 
eterization twice  daily.  Severe  constant  pain  in  the  lumbar  region.  The 
patient  cannot  move  legs  or  body  without  very  great  pain.  Sexual  powers 
present,  but  erections  are  painful  and  intercourse  produces  slight  pain. 
General  health  excellent,  no  loss  of  weight. 

Examination. — The  patient  is  well  nourished  and  his  lips  are  of  good 
color.  There  are  no  enlarged  glands.  The  lungs  and  heart  are  negative. 
The  arteries  are  considerably  sclerosed. 

Abdomen. — There  is  no  tenderness  in  the  region  of  the  kidneys  or  blad- 
der. Patient  locates  pain  in  the  lumbar  region  on  both  sides  and  in  the 
spinal  column.  There  is  no  tenderness  along  the  spine,  but  any  movement 
or  sudden  jar  causes  severe  pain  in  this  region.    Genitalia  negative. 


study  of  lJf5  Cases  of  Perineal  Prostatectomy.  439 

Rectal. — The  prostate  is  moderately  enlarged,  smooth,  firm,  but  not  of 
stony  hardness.  There  Is  slight  induration  in  the  region  of  the  seminal 
vesicles,  but  not  sufficient  to  suggest  cancer.  There  are  no  enlarged  glands 
in  the  pelvis,  the  rectum  is  smooth  and  soft. 

Cystoscopic. — Coude  catheter  passes  with  ease  and  withdraws  about  400 
cc.  residual  urine.  The  bladder  is  slightly  contracted  and  irritable.  The 
cystoscope  enters  with  ease,  but  there  is  some  hemorrhage,  making  exami- 
nation somewhat  unsatisfactory.  The  middle  lobe  is  moderately  enlarged, 
and  the  lateral  lobes  are  only  slightly  intravesically  enlarged.  There  is 
no  stone  present. 

Urinalysis. — Acid,  1020,  no  sugar,  albumin  in  small  amount.  Microscop- 
ically pus  cells,  bacilli,  no  casts. 

Operation,  February  2,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  moderately  enlarged  and  removed 
each  in  one  piece.  The  median  lobe  came  away  in  three  pieces,  and  was 
moderately  enlarged.  There  was  no  stone  present.  The  ejaculatory  ducts 
were  not  removed.  The  wound  was  closed  as  usual  with  double  tube  and 
gauze  drainage.  The  patient  stood  the  operation  well,  the  pulse  at  the 
end  being  85.  The  patient  reacted  well,  temperature  rose  to  101°  on  the 
first  two  days  after  the  operation,  after  that  remained  normal.  The  gauze 
and  tubes  were  removed  in  48  hours,  and  on  the  third  day  considerable 
urine  passed  through  the  anterior  urethra.  On  the  third  day  the  follow- 
ing note  was  made:  The  patient  voids  urine  three  times  a  day.  He  has 
control  sufficiently  good  so  that  he  can  use  the  commode.  His  general  con- 
dition is  excellent.  For  one  week  after  the  operation  he  was  almost  free 
from  pain  in  the  back,  on  the  eighth  day  he  had  several  attacks  of  pain 
in  the  lumbar  region  which  caused  him  to  cry  out  and  double  up.  The 
perineal  fistula  closed  on  the  20th  day,  and  patient  at  that  time  voided 
urine  at  intervals  of  five  hours  and  had  perfect  control.  He  was  confined 
to  bed,  however,  owing  to  severe  paroxysmal  pains  in  the  lumbar  region. 
The  patient  described  the  pain  as  throbbing  in  character  and  located 
in  the  back  bone.  It  radiated  only  once  down  the  right  leg,  there  was  no 
constriction  like  pain,  no  girdle  sensation,  no  numbness,  tingling  or  weak- 
ness in  the  legs.  Any  sudden  motion,  turn  or  jar,  coughing  or  sneezing, 
produces  the  pain.  The  attacks  come  on  some  days  at  intervals  of  from 
15  to  20  minutes  and  last  from  two  to  three  minutes.  During  this  time 
the  patient  is  drawn  up,  legs  and  thighs  flexed,  and  the  abdominal  muscles 
are  rythmically  contracted  and  relaxed  with  the  pain.  Examination  shows 
no  sensory  or  motor  disturbance  in  legs,  thighs  or  abdomen.  There  is  no 
incontinence  of  urine  or  feces.  The  reflexes  at  the  knee  and  ankle  are  ex- 
aggerated equally  on  both  sides.  There  is  no  point  of  tenderness  along 
the  spine.  The  patient  was  discharged  at  his  own  request  on  the  21st  day. 
He  still  continued  to  suffer  severe  attacks  of  pain  as  described  above.  He 
was  able  to  retain  urine  for  five  hours,  and  had  no  difficulty  in  urination, 
no  pain  in  the  bladder  nor  urethra.  An  x-ray  examination  of  the  spine  was 
negative. 


440  Hugli  E.  Young. 

Isote. — The  pain  in  the  back  was  very  puzzling  in  character,  and  sug- 
gested somewhat  spinal  tumor,  but  examination  was  negative  in  every  way. 

September  18,  1906. — Letter.  I  void  urine  naturally  at  intervals  of 
three  or  four  hours  during  the  day  and  two  or  three  times  at  night.  I 
am  getting  along  fairly  well,  but  don't  get  strength  in  hips  and  back. 
After  three  or  four  hours  of  work  or  exercise  I  have  to  lie  down.  I  suf- 
fer pain  in  my  hips  except  when  sleeping.  I  do  not  have  erections.  My, 
general  health  is  fair  and  I  have  gained  25  pounds.  The  perineal  fistula 
has  remained  closed,  and  I  am  cured. 

Pathological  report. — The  specimen,  G.  U.  240,  consists  of  the  right,  left, 
and  median  lobes  of  the  prostate,  and  weighs  about  30  gm.  The  right 
lateral  lobe  measures  6  x  2.5  x  2  cm.  Its  surface  is  composed  of  numerous 
small  spheroids  bound  together  by  a  thin  capsule.  It  is  soft  and  on  sec- 
tion is  very  succulent  and  shows  great  numbers  of  small  and  large  sphe- 
roids with  little  intervening  tissue.  There  are  numerous  small  yellowish 
areas,  evidently  necrotic  epithelium.  There  are  numerous  dilated  acini. 
The  left  lateral  lobe  measures  4x3x2.5  cm.  and  is  similar  to  the  right. 
The  middle  lobe  is  in  three  pieces,  the  largest  2.5x2x2  cm.,  and  similar 
in  character  to  the  lateral  lobes.  No  mucous  membrane,  no  ejaculatory 
ducts,  no  calculi. 

Microscopic  exaininatioji. — Microscopically,  the  gland  tissue  distinctly 
predominates.  The  acini  are  in  part  moderately  dilated,  in  other  portions 
have  undergone  cystic  degeneration,  while  in  still  other  areas  the  acini 
are  about  normal  in  size.  In  a  few  areas  the  epithelium  seems  to  grow 
into  the  lumina  of  the  acini  in  a  rather  loose  irregular  manner,  but  no- 
where showing  any  tendency  to  infiltrate  the  surrounding  stroma.  Both 
in  the  lobulated  areas  and  in  the  intervening  portions,  there  is  a  fair 
amount  of  chronic  prostatitis  leading  in  many  places  to  the  formation  of 
new  connective  tissue  about  the  acini,  and  often  infiltrating  in  an  irregu- 
lar manner  the  interstitial  stroma.  The  stroma  contains  a  fair  amount 
of  muscle  fibers. 

Case  131. — Consider a'ble  enlargement  of  median  and  lateral  lobes.  Su- 
prapubic fistula  of  two  years'  duration.    Cured. 

No.  1195.     J.  T.  H.,  age  74,  married,  admitted  February  S,  1906. 

Complaint. — "  Prostatic  obstruction,  suprapubic  fistula." 

Patient  had  gonorrhoea  as  a  boy,  no  complications  or  stricture  after- 
wards. 

Present  illness  began  15  years  ago  with  frequency  of  urination,  after 
that  there  was  a  gradual  increase  in  frequency  and  difiiculty,  and  hema- 
turia appeared  once  six  years  ago,  there  has  been  none  since.  About  two 
years  ago,  at  which  time  patient  was  getting  up  five  or  six  times  at  night 
to  urinate,  acute  retention  of  urine  came  on,  he  could  not  be  catheterized 
and  suprapubic  cystostomy  was  performed.  Numerous  vesical  calculi  were 
removed.  Previous  to  this  he  had  had  no  pain  in  the  bladder.  The  supra- 
pubic sinus  has  been  kept  open,  and  he  now  wears  a  small  rubber  catheter, 
but  is  bothered  considerably  with  leakage. 


study  of  lJj.5  Cases  of  Perineal  Prostatectomy.  441 

Status  prcEsens. — Does  not  void  naturally,  wears  a  suprapubic  catheter. 
No  pain,  no  hematuria,  no  loss  of  weight.     General  health  is  excellent. 

Sexual  powers. — No  erections  for  several  months. 

Examination.- — Healthy  looking  man  with  marked  arcus  senilis.  Lips 
are  of  good  color.  The  lungs  are  negative  with  the  exception  of  a  few 
rales.  The  heart  is  negative.  Arteries  sclerotic.  The  abdomen  is  nega- 
tive with  the  exception  of  suprapubic  fistula  through  which  urine  escapes. 
Urine,  sp.  gr.  1021,  neutral,  no  sugar,  moderate  amount  of  albumen.  Mi- 
croscopically, pus,  red  blood  corpuscles,  numerous  organisms. 

Genitalia. — Both  epididymes  are  enlarged,  indurated  and  tender. 

Rectal. — The  prostate  is  considerably  hypertrophied,  about  the  size  of  a 
small  orange.  It  is  smooth,  firm,  but  elastic.  There  are  no  areas  of  indu- 
ration and  no  tenderness.  Extending  upward  and  outward  from  the  upper 
end  of  each  lateral  lobe  is  an  area  of  induration  in  the  region  of  the  semi- 
nal vesicle  which  is  more  extensive  on  the  left  than  on  the  right.  This 
induration  is  not  of  stony  hardness,  but  is  quite  firm  and  the  surface  is  a 
little  irregular.  On  the  left  side  there  is  a  line  of  induration  which  ex- 
tends back  along  the  lateral  wall  of  the  pelvis  towards  the  sacral  fossa. 
No  enlarged  glands  can  be  felt.  In  the  intervesicular  space  there  is  a 
pleateau  of  moderate  induration  continuous  with  the  vesicles  on  each 
side  and  with  a  sharp  concaved  upper  border. 

Remark. — The  prostate  does  not  suggest  malignancy,  and  while  the  dis- 
tribution of  the  induration  in  the  region  of  the  vesicles  and  intervesicular 
space  suggests  carcinoma,  the  induration  is  of  less  degree  than  we  have 
seen  in  such  cases. 

Cystoscopic. — A  coude  catheter  passes  with  ease,  and,  by  stopping  up  the 
suprapubic  fistula,  cystoscopy  is  possible,  but  not  very  satisfactory  on  ac- 
count of  hemorrhage.  The  cystoscope  shows  a  median  lobe  of  considerable 
size,  and  also  a  moderate  intravesical  enlargement  of  the  lateral  lobes. 

Operation,  February  9,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  prostate  was  markedly  adherent  to  the  rectum  and 
freed  with  difficulty.  The  lateral  lobes  were  considerably  enlarged  and 
were  enucleated  each  in  one  piece  with  the  exception  of  a  small  anteriorly 
projecting  portion  of  the  right  lobe.  The  median  lobe,  which  was  quite 
large,  was  drawn  into  the  right  lateral  cavity  and  enucleated  with  ease, 
small  area  of  mucous  membrane  being  excised  with  it.  Examination  with 
the  finger  showed  no  remaining  prostatic  enlargement,  and  no  calculus. 
Closure  as  usual  with  gauze  and  double  tube  drainage.  Infusion  on  the 
table  and  continuous  irrigation  on  return  to  ward.  The  patient  stood  the 
operation  well,  his  pulse  at  the  end  being  105°. 

Convalescence. — There  was  no  elevating  of  temperature  and  pulse  fol- 
lowing the  operation,  but  after  the  fourth  day  there  was  a  slight  up  and 
down  temperature,  and  on  the  tenth  day  a  chill  and  temperature  of  104°. 
On  the  14th  day  there  was  another  chill  and  temperature  of  103°,  but  after 
the  16th  day  the  temperature  remained  normal.  The  irrigation  was  kept 
up  for  10  hours,  gauze  and  tubes  were  removed  at  the  end  of  24  hours. 
On  the  third  day  a  small  quantity  of  urine  passed  through  the  penis,  but 


443  Hugli  H.  Young. 

most  of  it  escaped  through  the  suprapubic  fistula.  The  perineal  sutured 
wound  suppurated  and  broke  down  on  the  left  side,  and  several  pieces  of 
necrotic  capsule  of  prostate  came  away.  This  was  the  cause  of  the  fever 
mentioned  above.  The  perineal  fistula  closed  on  the  30th  day,  and  the 
suprapubic  wound  on  the  34th  day.  The  patient  was  discharged  on  the  43d 
day,  able  to  retain  urine  for  three  hours  and  voiding  sometimes  as  much 
as  400  cc.  at  a  time,  2000  cc.  in  24  hours.  There  was  slight  leakage  if  pa- 
tient had  to  hold  urine  long  after  desire  to  void  came  on. 

Rectal. — The  seminal  vesicles  are  indurated,  not  of  stony  hardness  and 
not  nodular.  They  are  softer,  elastic  and  compressible.  The  intervesicular 
induration  does  not  suggest  malignancy.  In  the  region  of  the  prostate  a 
small,  rounded  mass,  smaller  than  normal  prostate,  is  felt.  There  are  no 
enlarged  glands.     Patient  is  in  excellent  condition. 

September  22,  1906. — Letter.  I  void  urine  naturally  about  every  two 
hours,  two  or  three  times  at  night,  two  or  three  ounces  at  a  time,  but 
suffer  no  pain.  I  have  not  had  erections  for  two  years.  Physician  re- 
ports that  the  fistula  is  completely  closed. 

Pathological  report. — 'The  specimen,  G.  U.  245,  consists  of  the  three  lobes 
of  the  prostate,  each  removed  in  one  piece,  and  weighs  in  all  about  40  gm. 
The  left  lobe  measures  5x3x2  cm.,  is  lobulated,  firm,  but  elastic,  and  on 
section  is  very  juicy.  There  are  numerous  spheroids,  some  dilated  ducts, 
one  retention  cyst  containing  greenish  material,  and  about  1.5  cm.  in  diam- 
eter. The  right  lateral  and  middle  lobes  have  been  removed  in  one  piece, 
the  right  measuring  3.5  x  2.5  x  2.5  cm.,  is  larger  than  the  other  two  lobes 
measuring  5x3x3  cm.  It  is  considerably  torn,  composed  of  numerous 
large  lobules,  and  contains  some  mucous  membrane  on  its  anterior  sur- 
face. On  section  it  is  similar  in  character  to  the  lateral  lobes.  The  ejac- 
ulatory  ducts  have  not  been  removed,  no  calculus. 

Microscopic  exam.ination. — This  hypertrophy  is  also  of  the  benign  aden- 
omatous type.  The  glands  show  very  marked  complexity,  owing  to  invagi- 
nations of  the  wall  and  papillomatous  outgrowths.  In  areas  there  is  mod- 
erate cystic  dilatation.  In  some  of  the  glandular  lobules  the  acini  are 
small,  closely  grouped  with  a  rather  small  amount  of  stroma.  In  the 
areas  outside  of  the  lobules  the  stroma  is  quite  dense,  and  contains  a 
great  deal  of  fibrous  tissue  with  numerous  areas  of  chronic  inflammation. 
Within  the  lobules  there  are  also  limited  areas  of  periacinous  and  round 
cell  infiltration.  The  stroma  contains  somewhat  more  fibrous  than  muscle 
tissue.     The  same  type  of  hypertrophy  is  present  in  all  three  lobes. 

Case  132. — Moderate  hypertrophy  of  median  and  lateral  lobes.  Catheter- 
ism.    Cured.    Followed  three  months. 

No.  1201.    M.  S.,  age  67,  married,  admitted  February  10,  1906. 

Complaint. — "  Frequency  of  urination." 

No  definite  history  of  gonorrhcea,  but  had  a  discharge  10  years  ago. 

Present  illness  began  about  11  years  ago  with  frequency  of  urination. 
This  gradually  increased  until  three  months  ago  when  he  had  to  urinate 
six  times  during  the  night  and  occasionally  had  dribbling.     He  has  had 


study  of  IJi-o  Cases  of  Perineal  Prostatectomy.  4A3 

no  pain  except  a  burning  during  urination.    For  the  last  two  weeks  urina- 
tion lias  been  very  frequent,  considerable  pain  in  the  bladder. 

Sexual  powers. — Erections  and  desire  have  been  absent  for  10  years. 

Exaviination. — Patient  is  a  well  nourished  man,  but  looks  sick.  Lips 
of  fair  color.    The  chest  and  abdomen  are  negative. 

Rectal. — The  prostate  is  moderately  hypertrophied,  smooth,  round,  elas- 
tic, not  very  painful.  At  the  upper  end  of  the  left  lateral  lobe  is  a  small 
rounded,  prominent  nodule,  smaller  than  a  cherry,  which  is  harder  than 
the  rest  of  the  prostate.  It  does  not  seem  to  be  continuous  with  the  semi- 
nal vesicle,  both  of  which  are  soft  and  not  surrounded  by  adhesions. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  400  cc.  resid- 
ual urine.  The  cystoscope  shows  two  moderately  enlarged  lateral  lobes 
with  a  deep  sulcus  between  them  in  front,  and  a  median  bar  of  small  size 
connecting  the  two  without  intervening  sulci.  The  examination  of  the 
bladder  is  unsatisfactory  on  account  of  hemorrhage. 

Urinalysis. — Acid,  1010,  albumin  in  small  amount,  microscopically  many 
red  blood  corpuscles  and  some  pus  cells,  no  bacteria. 

Preliminary  treatment. — The  patient  was  catheterized  twice  daily,  about 
300  cc.  residual  urine  being  found  each  time.  Several  hours  after  cath- 
eterization he  is  able  to  void  small  amounts  with  difiiculty  and  great  fre- 
quency.    Urotropia  and  water  in  abundance  given. 

Operation.  Feljruary  IJ^,  1906. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  posterior  surface  of  the  prostate  was  moderately 
enlarged.  The  lateral  lobes  were  easily  enucleated  without  tearing  the 
urethra  or  bladder.  A  small  median  bar  was  present  which  was  continu- 
ous with  two  small  lateral  masses  which  together  formed  a  collar  around 
the  prostatic  urethra.  It  was  quite  adherent  and  enucleated  in  three  pieces 
through  the  two  lateral  cavities  without  removing  any  mucous  membrane 
or  destroying  the  ejaculatory  ducts.  There  was  very  little  hemorrhage 
and  the  patient  stood  the  operation  well.  The  wound  was  closed  as  usual 
with  double  catheter  drainage  and  light  packs  for  the  lateral  cavities.  Pa- 
tient stood  the  operation  well,  pulse  at  the  end  75.  Infusion  and  continu- 
ous irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to 
102°  on  the  third  day  after  the  operation,  and  for  ten  days  there  was  a 
slight  daily  rise  to  101°,  after  that  the  temperature  was  normal.  The 
gauze  and  tubes  were  removed  on  the  second  day.  On  the  third  day  after 
the  operation  epididymitis  developed  on  both  sides,  but  was  only  slight 
in  character  and  subsided  after  a  week.  The  fistula  healed  very  slowly 
and  the  patient  was  not  discharged  until  the  40th  day.  He  was  then  able 
to  retain  urine  for  several  hours  and  felt  well. 

May  1-5,  1906. — The  patient  returns  for  examination.  He  voids  urine 
three  times  during  the  day  and  twice  at  night,  in  a  large  stream  without 
pain  or  incontinence.  The  perineal  fistula  healed  on  the  90th  day.  For 
two  years  previous  to  the  operation  the  patient  had  no  erections.  During 
the  past  two  weeks  he  has  had  several  firm  erections,  and  nocturnal  pollu- 
tions. 


4ri-i  HugTi  E.  Young. 

Examination. — The  patient  looks  well.  A  catheter  passes  with  ease  and 
finds  20  cc.  residual  urine.  The  bladder  is  large,  admitting  400  cc.  of  fluid. 
The  urine  is  acid,  contains  pus  and  bacilli.  The  perineal  wound  is  closed. 
There  is  no  stricture  present. 

July  12.  1906. — A  catheter  passes  with  ease,  there  is  no  residual  urine, 
bladder  capacity  375  cc. 

September  14,  1906. — The  perineal  wound  has  been  healed  for  some 
time.  Patient  voids  from  two  to  four  times  during  the  day  and  once  at 
night.     Urination  normal.     Erections  are  present. 

Patlwlogical  report. — The  specimen,  G.  U.  247,  consists  of  the  two  lateral 
lobes  and  a  median  lobe,  the  latter  in  two  pieces,  and  weighs  about  20  gm. 
The  left  lobe  is  the  larger  and  measures  3  x  2  x  2.5  cm.,  has  a  lobulated 
surface,  is  firm,  but  elastic.  The  section  presents  the  typical  picture  of  a 
glandular  hypertrophy,  but  with  well  marked  fibrous  bands.  The  right 
lobe  measures  2.5  x  2  x  2  cm.,  and  has  the  same  general  appearance  as  the 
left.  Four  small  seed  calculi  are  present  along  its  inner  surface.  The 
middle  lobe  consists  of  three  small  pieces,  the  largest  of  which  is  2x1x1 
cm.,  and  on  section  is  similar  in  appearance  to  the  lateral  lobes.  A  small 
bit  of  mucus  is  attached. 

Microscopic  examination. — Both  lateral  lobes  contain  stroma  and  gland 
tissue  in  varying  amount,  the  gland  tissue  for  the  most  part  predomi- 
nating. The  alveoli  in  the  glandular  areas  show  but  moderate  dilatation, 
except  in  a  few  areas  where  there  is  rather  marked  dilatation  with  in- 
tracystic  papillomatous  outgrowth,  giving  the  appearance  of  numerous 
acini  with  slender  bands  of  stroma.  The  stroma  is  rather  dense  as  a 
whole,  and  contains  more  fibrous  than  muscle  tissue.  Limited  areas  of 
prostatitis  with  interstitial  and  glandular  infiltration  of  a  rather  mild 
type  are  present.  The  median  bar  contains  practically  no  alveoli,  and 
consists  for  the  most  part  of  fibrous  tissue.  Here  and  there  evidences  of 
new  formed  connective  tissue  with  vestiges  of  gland  acini  are  to  be  noted. 

The  hypertrophy  in  the  lateral  lobes  is  a  glandular  one,  while  the  me- 
dian bar  is  fibrous. 

Case  133. — Small  prostate.  Slight  median  tar.  Residuum.  360  cc.  Cure. 
Followed  tJiree  months. 

No.  1204.    R.  L.  S.,  age  47,  married,  admitted  February  13,  1906. 

Complaint. — "  Frequency  and  difficulty  of  urination." 

No  history  of  gonorrhoea.  At  the  age  of  15  the  patient  fell  astride  of  a 
fence,  had  no  hemorrhage  from  the  urethra,  but  several  months  later  no- 
ticed that  the  urinary  stream  was  smaller  than  normal,  this  continued  up 
to  P.  I. 

Present  illness  began  about  10  years  ago  with  increase  frequency  of 
urination,  and  after  four  years  he  had  to  strain  very  severely  during  uri- 
nation and  make  numerous  efforts  before  urine  was  voided  to  afford  relief. 
His  physician  then  performed  internal  urethrotomy  for  a  stricture  one 
inch  from  the  meatus,  but  the  difficulty  in  urination  was  not  bettered. 
During  the  past  four  months  he  has  been  much  worse  and  has  suffered 


study  of  lJi5  Cases  of  Perineal  Prostatectomy.  445 

pain  in  the  hips  and  lower  portion  of  the  hack.  Two  years  ago  he  had  re- 
tention of  urine  for  four  days  and  required  catheterization,  but  no  instru- 
ments have  been  passed  since  that  time. 

8.  P. — ^Urination  every  hour  night  and  day.  Stream  small,  considerable 
straining  necessary,  never  any  dribbling.  Burning  along  the  urethra  dur- 
ing urination,  no  hematuria,  no  severe  pain. 

Sexual  powers. — Good  until  six  months  ago,  since  then  has  had  no  erec- 
tions and  no  sexual  desire.    Patient  has  not  lost  weight. 

Examination. — The  patient  is  a  pale,  thin,  frail  looking  man.  The  lungs 
are  negative. 

Heart. — There  is  a  slight  systolic  murmur  at  the  apex  and  the  heart  is 
a  little  enlarged.  The  arteries  are  thickened,  pulse  75,  tension  high.  Ab- 
domen and  genitalia  negative. 

Rectal. — ^^The  posterior  surface  of  the  prostate  does  not  appear  to  be  en- 
larged. It  does  not  bulge  towards  the  rectum,  is  soft,  smooth  and  free 
from  nodules.  The  seminal  vesicles  seem  atrophic  and  are  barely  palpable 
against  the  posterior  surface  of  the  bladder  which  appears  distinctly 
thickened.    The  rectal  sphincter  is  strong,  there  are  no  enlarged  glands. 

Urinalysis. — Cloudy,  acid,  1007,  albumin  in  small  amount,  no  casts,  pus 
and  bacilli  in  considerable  amount. 

Cystoscopic. — A  large  bougie-a-boule  detects  stricture  of  large  caliber 
about  five  inches  from  the  meatus.  A  No.  12-F  bougie  passes  with  ease 
and  enters  the  bladder.  Filiforms  pass  without  difficulty  and  followers 
up  to  22-F.  A  small  rubber  catheter  is  then  introduced  and  finds  360  cc. 
residual  urine.  The  cystoscope  shows  no  enlargement  of  the  lateral  lobes, 
and  a  very  small,  slightly  rounded  enlargement  of  the  median  portion  of 
the  prostate.  There  is  a  definite  but  shallow  cleft  on  each  side  of  the 
middle  lobe  and  a  small  pouch  behind  it  which  cannot  be  explored  with 
the  cystoscope.  The  ureters  are  situated  in  hypertrophied  ridges  and  are 
easily  seen.  The  lateral  and  posterior  surfaces  of  the  bladder  are  mark- 
edly trabeculated,  with  numerous  small  and  large  cellules.  At  the  vertex 
of  the  bladder  a  large,  irregular,  dark  opening,  probably  the  orifice  of  a 
large  diverticulum,  is  seen.  With  finger  in  rectum  and  cystoscope  in  ure- 
thra a  slight  but  definite  increase  in  the  median  portion  is  made  out. 

Preliminary  treatment. — Catheterization  three  times  daily  for  two  days. 
Urotropin  and  water  in  abundance.     450  cc.  residual  was  found. 

Operation,  February  15.  1006. — Ether.  Perineal  prostatectomy  by  the 
usual  technique.  The  lateral  lobes  were  no  larger  than  normal,  but  were 
enucleated  each  in  one  piece  with  some  difficulty.  Each  measured  about 
1%  cm.  in  diameter.  It  was  impossible  with  the  tractor  to  engage  the  me- 
dian portion  of  the  prostate.  The  urethra  was  therefore  opened  along  its 
left  lateral  wall  and  the  finger  inserted  into  the  bladder  after  dilating  a 
markedly  constricted  prostatic  orifice  which  seemed  to  be  surrounded  by 
a  fibrous  ring.  It  was  impossible  with  the  finger  to  expose  the  median 
portion  of  the  prostate,  and  a  long  forcep  was  used  to  grapple  it.  After 
that  the  median  portion  of  the  prostate,  with  the  mucous  membrane  cov- 
ering it,  was  excised  with  a  small  strip  of  the  left  lateral  margin  of  the 
Vol.  XIV.— 29. 


446  Hugh  H.  Young. 

prostate.  The  tissue  removed  measured  from  5  mm.  to  1  mm.  in  diam- 
eter and  about  2  cm.  in  length.  That  representing  the  median  portion  was 
white  and  fibrous,  that  representing  the  lateral  was  muscular.  After  this 
excision  a  very  large  prostatic  orifice  was  present.  Examination  with  the 
finger  showed  no  remaining  prostatic  obstruction.  The  wound  was  closed 
as  usual  with  double  tube  drainage  and  light  packs  for  the  lateral  cavities. 
The  patient  stood  the  operation  well,  infusion  and  continuous  irrigation 
on  return  to  the  ward. 

ConvaJescence. — -The  patient  reacted  well.  Temperature  rose  to  101.8° 
on  the  day  after  the  operation,  but  after  that  it  remained  practically  nor- 
mal. The  gauze  and  tubes  were  removed  on  the  day  after  the  operation 
and  the  patient  was  out  of  bed  on  the  third  day.  Urine  began  to  flow 
through  the  penis  on  the  sixth  day  and  the  perineal  fistula  closed  finally 
on  the  17th  day.  Interval  urination  was  established  seven  days  after  the 
operation,  and  he  has  had  no  incontinence  since.  He  was  discharged  from 
the  hospital  on  the  20th  day.  At  that  time  he  was  able  to  retain  urine 
four  or  five  hours,  voided  without  diflBculty,  hesitation  and  in  a  large 
stream.  The  wound  was  closed.  No.  28  sound  passed  into  the  bladder 
with  ease  without  detecting  any  stricture.  A  silver  catheter  found  10  cc. 
residual  urine. 

March  12,  1906. — Letter.  Urination  is  normal.  I  feel  better  than  I  have 
for  years.     Erections  have  returned  and  sexual  desire  is  strong. 

May  8.  1906. — Letter.  I  void  urine  naturally  and  easily  at  intervals  of 
four  hours  during  the  day  and  seven  hours  at  night,  about  a  pint  at  a 
time.  I  have  no  pain.  Sexual  intercourse  is  entirely  satisfactory,  being 
apparently  normal  in  every  respect. 

September  12,  1906. — I  void  urine  naturally  three  or  four  times  during 
the  day  and  none  at  night  in  normal  amounts.  I  suffer  no  pain.  Sexual 
intercourse  is  satisfactory.     I  am  perfectly  cured. 

Pathological  report. — 'The  specimen,  G.  U.  248,  consists  of  three  small 
bits  of  tissue  representing  the  three  lobes  of  the  prostate,  and  weighs  less 
than  5  gm.  The  lateral  lobes  consist  each  of  a  small  mass  about  1  cm. 
in  diameter,  and  appear  to  be  composed  largely  of  fibrous  tissue.  There 
are  no  spheroidal  lobules,  and  the  picture  does  not  resemble  that  of  ordi- 
nary hypertrophy.  The  median  portion  measures  4  x  1  x  .5  cm.,  the  larger 
end  is  white  and  fibrous,  the  other  half  apparently  muscle  (vesical).  The 
mucous  membrane  is  not  visible.  Ejaculatory  ducts  not  removed,  no  cal- 
culus. 

Microscopic  examination. — ^The  section  from  the  median  bar  shows 
largely  fibrous  tissue  with  here  and  there  atrophic  looking  acini.  About 
nearly  all  of  the  acini  there  is  a  well  marked  periacinous  inflammatory 
infiltration,  which  often  extends  well  out  into  the  interstitial  tissue.  The 
stroma  is  mostly  made  up  of  fibrous  tissue,  although  here  and  there  one 
finds  areas  where  considerable  smooth  muscle  is  present.  The  appearance, 
both  microscopically  and  macroscopically,  is  that  of  normal  prostatic  tissue 
which  has  undergone  considerable  inflammatory  change. 


study  of  145  Cases  of  Perineal  Prostatectomy.  447 

Case  134. — Slight  enlargement  of  lateral  lodes.  Small  median  lobe.  In- 
termittent complete  retention.    Symptoms  suggesting  tabes.    Cure. 

No.  1230.     S.  H.  S.,  age  62,  married,  admitted  March  6,  1906. 

Complaint. — "  Difficulty  in  urination.     Catheterism." 

Several  attacks  of  gonorrhoea  in  early  manhood  with  posterior  involve- 
ment. Twelve  years  ago  had  marked  polyuria  for  one  year.  During  this 
time  he  would  void  from  six  to  eight  quarts  of  urine  a  day.  After  that 
had  weakening  of  sexual  powers.  Absence  of  satisfactory  ejaculation. 
Eleven  years  ago  a  sound  was  passed  by  a  physician,  and  on  the  next  day 
the  patient  went  into  a  coma  and  was  unconscious  three  days  and  three 
nights.  No  attacks  of  unconsciousness  since,  but  double  vision  persisted 
for  six  months  after  the  attack. 

Present  illness. — -It  is  difficult  to  state  the  time  of  onset.  For  the  past 
12  years  patient  has  arisen  at  least  once  at  night  to  urinate,  and  the 
stream  has  been  smaller  and  normal.  There  has  never  been  any  inconti- 
nence. Knee  jerks  were  absent  on  examination  10  years  ago,  but  there  has 
been  no  unsteadiness  of  gait  nor  swaying  when  washing  face.  Never  any 
pain  in  limbs.  His  urinary  trouble  has  gotten  gradually  worse,  but  he 
did  not  have  complete  retention  of  urine  until  eight  months  ago  when 
he  was  catheterized  for  the  first  time.  Since  then  he  has  been  catheterized 
for  short  periods  four  or  five  times  with  intervening  periods  of  fairly  free 
urination.  During  the  past  three  months  he  has  had  a  fairly  constant 
dull  pain  in  the  hypogastric  region  with  occasional  sharp  exacerbations 
in  which  it  would  radiate  into  the  groin;  no  pain  in  back,  testicles  or 
limbs.    No  note  of  hematuria  or  pain  in  the  urethra. 

Status  prwsens. — Frequency  of  urination,  particularly  during  the  night 
(twice).  Practically  no  increase  in  frequency  during  the  day.  Stream 
small  and  slow  (considerable  effort  required).  Dull  pain  in  hypogastric 
region.  Occasional  retention  requiring  catheterization,  three  pints  being 
withdrawn.    No  difficulty  in  walking  in  the  dark,  no  lancinating  pains. 

Sexiial  powers. — Ejaculations  have  been  absent  for  10  years.  Sexual 
desire  has  gradually  decreased  and  during  the  past  year  has  been  absent, 
and  there  have  been  no  erections.  The  patient  has  lost  20  pounds  during 
the  past  four  months,  but  he  feels  well. 

Examination. — Patient  is  fairly  well  nourished  with  lips  of  good  color. 
The  pupils  are  equal  and  react  to  light  and  accommodation.  The  knee 
jerks  are  not  obtained  naturally  nor  on  reinforcement.  There  is  no  ankle 
clonus.  When  patient  stands  with  eyes  closed  and  head  elevated  there  is 
a  decided  swaying  of  the  body.  The  co-ordination  of  the  arms  and  legs 
are  good.     The  heart,  lungs  and  abdomen  are  negative. 

Genitalia. — ^The  left  epididymis  is  indurated,  but  very  little  enlarged. 
There  are  no  enlarged  glands  present. 

Rectal. — The  prostate  is  moderately  enlarged,  forming  a  globular  mass 
about  the  size  of  a  small  orange,  the  lateral  lobes  being  equally  enlarged, 
and  the  median  furrow  and  notch  being  absent.  The  prostate  is  smooth, 
firm,  elastic.  There  are  no  nodules  or  areas  of  induration  present.  The 
seminal  vesicles  are  negative.  There  is  no  intervesicular  mass,  no  tender- 
ness and  the  rectum  is  normal. 


448  Hugli  H.  Young. 

Urinalysis. — Acid,  1012,  albumin  in  small  amount,  no  sugar,  pus  and 
bacilli  in  moderate  number. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  400  cc.  resid- 
ual urine,  and  a  bladder  capacity  of  550  cc.  There  is  no  stricture  present. 
The  cystoscope  shows  a  very  slight  intravesical  enlargement  of  the  lateral 
lobes  and  a  prominent  pedunculated  median  lobe  with  a  deep  sulcus  on 
each  side,  particularly  the  left.  The  bladder  is  only  slightly  inflamed. 
The  right  ureter  is  easily  seen,  but  the  left  is  obscured  by  the  middle  lobe. 
There  is  no  stone  present.  With  finger  in  rectum  and  cystoscope  in  ure- 
thra, the  beak  is  easily  felt  and  the  median  portion  of  the  prostate  is  only 
slightly  thickened  (with  the  instrument  in  a  sulcus  to  the  left  of  the  lat- 
eral lobe). 

Remark. — The  history  of  this  case  is  peculiar,  and  suggests  tabes,  but 
the  absence  of  lightning  pains  and  eye  symptoms  seem  to  exclude  this, 
and  the  presence  of  definite  hypertrophy,  particularly  of  the  median  lobe, 
offers  sufiicient  explanation  for  urinary  symptoms,  difficulty  of  urination, 
straining,  occasional  complete  retention.  The  patient's  desire  for  relief 
seems  warranted  and  operation  was  decided  upon. 

Operation,  March  9,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  only  moderately  enlarged,  and  each 
was  removed  in  several  pieces.  A  small  globular  median  lobe  about  2% 
cm.  in  diameter  was  enucleated  through  one  of  the  lateral  cavities  with- 
out destroying  the  ejaculatory  ducts.  The  wound  was  closed  as  usual  with 
tubes  and  gauze  drainage.  The  patient  stood  the  operation  well.  Pulse 
good  at  the  end.     Submammary  infusion  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  irrigation  was  discon- 
tinued after  12  hours,  the  gauze  and  tubes  were  removed  on  the  day  after 
the  operation,  and  the  patient  was  up  in  a  chair  on  the  third  day.  On  the 
second  day  the  urine  passed  through  the  penis  at  intervals,  and  on  the 
sixth  day  the  patient  was  able  to  retain  urine  for  four  hours,  and  had  no 
pain.  The  perineal  fistula  closed  finally  on  the  22d  day,  and  the  patient 
left  the  hospital  on  the  24th  day  in  excellent  condition,  able  to  retain 
urine  for  three  hours,  no  dribbling  or  other  complications.  On  the  27th 
day  examination  showed  the  wound  healed,  a  catheter  passed  with  ease 
and  found  only  5  cc.  residual  urine.  Rectal  examintion  showed  no  indu- 
ration in  the  region  of  the  seminal  vesicles.  Urine  was  acid  and  con- 
tained bacilli  in  moderate  number.  Patient  was  able  to  retain  urine  for 
four  hours  and  had  no  incontinence. 

May  9,  1906. — Letter.  I  am  doing  finely  and  feel  like  you  have  given  me 
a  new  lease  on  life.     I  have  perfect  control  and  am  very  well. 

September  IJf,  1906. — Letter.  I  void  urine  three  or  four  times  during 
the  day  and  once  at  night,  about  eight  ounces  at  a  time.  I  have  had  no 
erections,  but  these  were  absent  before  operation.  Have  gained  20  pounds 
in  weight  and  am  perfectly  cured. 

Pathological  report. — The  specimen,  G.  U.  254,  consists  of  three  lobes  of 
the  prostate  removed  in  five  pieces,  and  weighing  about  18  gm.     The  left 


study  of  1J^5  Cases  of  Perineal  Prostatectomy.  449 

lobe  is  a  mass  2.5  x  1.5  x  1  cm.,  soft  and  on  section  very  succulent  and 
contains  numerous  retention  cysts  and  dilated  ducts.  Spheroidal  arrange- 
ment of  the  tissue  is  indistinctly  shown.  The  middle  lobe  is  about  the 
same  size  as  the  left,  is  firm,  but  elastic,  and  on  section  rather  homo- 
geneous in  appearance.  The  ducts  are  dilated,  and  there  is  no  spheroidal 
arrangement.  The  right  lobe  consists  of  five  pieces,  the  largest  of  which 
is  4  X  2  X  1.5  cm.,  and  is  lobulated.  The  small  pieces  are  homogeneous  but 
soft,  and  there  are  no  dilated  acini.  No  mucous  membrane,  no  ejacula- 
tory  ducts,  no  calculus. 

Microscopic  examination. — The  hypertrophy  of  the  left  lobe  is  of  a  gland- 
ular type  with  dilatation  and  cystic  degeneration  of  the  acini.  There  is 
present,  however,  a  rather  large  amount  of  stroma. 

In  the  middle  and  right  lateral  lobes,  the  hypertrophy  is  of  a  rather 
fibro-muscular  type,  the  different  acini  being  separated  by  rather  broad 
bands  of  stroma.  In  the  latter  two  lobes  the  acini  are  somewhat  dilated, 
but  their  lumina  are  comparatively  regular,  there  being  but  few  pro- 
jections from  the  lining  wall.  About  many  of  the  acini  there  has  been 
formed  concentric  layers  of  new  inflammatory  tissue,  which  is  producing 
compression.  The  stroma  shows  a  fair  amount  of  round  cell  infiltration, 
and  there  is  present  a  large  amount  of  muscle.  The  arteries  exhibit  very 
little  if  any  thickening.  We  have  here  a  hypertrophy  of  the  fibro-muscular 
type  in  the  middle  and  right  lateral  lobes,  while  the  left  is  a  glandular 
one. 

Case  135. — Moderate  liypertrophy  of  median  and  lateral  lobes.  Two 
vesical  calculi.     Catheterism.     Cure.     Recent  case. 

S.     No.  18,978.     W.  C.  L.,  age  62,  married,  admitted  April  3,  1906. 

Complaint. — "  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  six  years  ago  with  difficulty  of  urination.  Since 
then  there  has  been  a  gradual  increase  in  the  difficulty  and  frequency, 
there  has  been  considerable  straining  and  the  stream  has  become  small. 
Fifteen  months  ago,  following  a  horseback  ride,  he  had  hematuria  once, 
and  a  second  attack  four  months  later.  His  physician  says  that  he  had 
two  attacks  of  renal  colic,  characterized  by  acute  pain  in  the  left  kidney 
radiating  into  the  left  groin,  requiring  morphia  first  21  months  ago  and 
second  9  months  ago.  During  the  past  nine  months  hematuria  has 
been  frequent,  and  there  has  been  intense  pain  at  the  end  of  urination 
along  the  urethra.  He  has  not  had  complete  retention  of  urine,  but  for 
the  past  four  weeks  has  used  the  catheter  twice  daily,  but  has  never  evac- 
uated more  than  half  an  ounce  of  residual  urine. 

Status  prcesens. — Urination  about  every  hour  night  and  day.  Consider- 
able difficulty,  pain,  occasionally  hematuria.  No  loss  of  weight.  Uses 
catheter  twice  daily,  but  finds  very  little  residual  urine. 

Sexual  poioers. — No  note  made. 

Examination. — ^The  patient  is  quite  fat,  his  lips  are  of  good  color.  The 
lungs  are  negative.  The  heart  is  enlarged  and  there  is  a  slight  systolic 
murmur  at  the  apex.     The  abdomen  is  negative. 


450  Hugh  H.  Young. 

Rectal. — The  prostate  is  moderately  enlarged,  smooth,  firm,  no  nodules 
or  areas  of  marked  induration. 

Cystoscopic  examination. — A  catheter  passes  with  ease  and  finds  200  cc. 
residual  urine.  The  bladder  is  contracted  and  irritable,  and  examination 
produces  hemorrhage,  rendering  cystoscopy  unsatisfactory. 

Urinalysis. — Cloudy,  acid,  1021,  no  sugar,  albumin  in  small  amount, 
microscopically,  pus  cells,  bacteria,  a  few  granular  casts. 

Operation,  April  5,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.     Lithotomy. 

The  lateral  lobes  were  moderately  enlarged  and  were  removed  each  in 
one  piece.  The  middle  lobe,  which  measured  about  3  cm.  in  diameter  was 
removed  through  one  of  the  lateral  cavities,  a  small  piece  of  mucous  mem- 
brane being  excised.  The  floor  of  the  urethra  and  ejaculatory  ducts  were 
preserved  intact.  The  urethra  was  divided  along  the  lateral  wall,  and  the 
neck  of  the  bladder  dilated,  and  two  small,  oval  calculi  removed.  The 
wound  was  closed  as  usual  with  double  tube  and  gauze  drainage.  The 
patient  stood  the  operation  well,  pulse  at  the  end  being  95. 

Convalescence.— 'Yov  two  days  after  the  operation  his  temperature  rose 
to  101°,  but  after  that  was  normal.  The  irrigation  was  discontinued  at 
the  end  of  12  hours,  tubes  removed  at  the  end  of  30  hours  and  the  gauze 
at  the  same  time.  The  patient  was  up  in  a  chair  on  the  third  day,  urine 
began  to  flow  through  the  urethra  on  the  sixth  day.  The  fistula  closed  on 
the  16th  day,  and  the  patient  was  discharged  from  the  hospital  on  the  19th 
day.  At  that  time  he  was  able  to  retain  urine  for  two  hours,  voided  with- 
out pain  and  in  a  large  stream,  had  no  incontinence,  but  slight  precipi- 
tancy, and  had  had  no  complications  and  no  instrumentation. 

June  14,  1906. — Letter.  I  void  urine  fairly  naturally  from  one-quarter 
to  one-half  a  pint  at  a  time.  I  have  no  pain.  My  general  health  is  good. 
The  wound  has  remained  closed  and  I  consider  myself  cured. 

September  14,  1906. — ^Letter.  The  perineal  fistula  closed  about  five 
weeks  after  the  operation.  I  void  urine  naturally,  six  or  eight  times  dur- 
ing the  day  and  seldom  more  than  once  at  night,  about  three-fourths  of  a 
pint  at  a  time.  I  have  had  no  erections.  My  general  health  is  good,  "  am 
nearly  cured." 

Pathological  report. — The  specimen,  G.  U.  261,  consists  of  the  three 
lobes  of  the  prostate,  each  of  which  has  been  removed  in  one  piece,  and 
weighs  about  20  gm.  The  right  lobe  is  an  oval  mass  3x2x2  cm.,  elas- 
tic, lobulated,  and  on  cross  section  shows  numerous  retention  cysts,  a  few 
small  calculi  in  the  periphery,  and  as  a  whole  is  quite  glandular.  The  left 
lobe  is  about  the  same  size  as  the  right,  is  also  elastic  and  on  section 
shows  numerous  spheroidal  bodies  firm  in  consistency  and  yellowish  in 
color,  with  a  considerable  amount  of  stroma.  The  middle  lobe  measures 
3x2.5x2  cm.  Attached  to  its  upper  end  is  a  small  piece  of  mucous  mem- 
brane. It  is  lobulated,  elastic  and  on  section  appears  very  glandular. 
There  are  no  areas  suggesting  carcinoma.  Seed  calculi  are  present  in  all 
of  the  lobes.    The  ejaculatory  ducts  have  not  been  removed.    Two  oblong 


study  of  lJf.5  Cases  of  Perineal  Prostatectomy.  451 

stones,  each  about  1.7  x  1.3  x  1  cm.  with  smooth,  white  surfaces,  have  been 
removed. 

Microscopic  examination.— ^he  hypertrophy  is  a  distinctly  glandular 
one  with  arrangement  in  lobules.  The  acini  are  for  the  most  part  small, 
but  show  very  active  proliferation,  there  being  present  very  numerous  in- 
traacinous  projections.  Often  in  the  glandular  areas  the  stroma  separat- 
ing the  acini  is  very  delicate,  and  apparently  consists  almost  entirely  of 
fibrous  tissue.  The  epithelium  lining  the  acini  varies  a  great  deal,  portions 
of  acini  having  but  a  single  layer  of  high  columnar  cells,  in  other  points 
the  epithelium  is  many  layers  thick,  the  superficial  layer  being  of  the  tall, 
columnar  variety.  The  branching  and  union  of  the  papillomatous  out- 
growths give  the  appearance  of  a  great  increase  in  the  number  of  acini. 
The  stroma  is  for  the  most  part  composed  of  connective  tissue,  although 
here  and  there  areas  are  encountered  where  there  is  a  definite  amount  of 
smooth  muscle.  There  is  no  evidence  of  prostatitis  in  sections  examined. 
The  arteries  seem  about  normal. 

Case  136. — -Moderate  enlargement  of  lateral  and  median  loie.  Residual 
urine  600  cc.     Cured.    Recent  case. 

S.  No.  18,993.     P.  C.  G.,  age  69,  married,  admitted  April  7,  1906. 

Complaint. — "  Incontineace  of  urine." 

No  history  of  gonorrhcea.  Since  early  manhood  the  patient  has  had  to 
arise  two  or  three  times  at  night  to  urinate.  There  has  been  no  increased 
frequency  of  urination  in  recent  years.  Two  years  ago  he  began  to  have 
incontinence  of  urine  every  night,  there  was  no  incontinence  during  the 
day  and  no  increased  frequency  of  urination,  but  micturition  was  impera- 
tive when  the  desire  came  on.  His  condition  has  remained  about  the  same 
for  two  years. 

S.  P. — Micturition  at  intervals  of  three  or  four  hours  during  the  day. 
"Wets  the  bed  every  night.  A  sharp  pain  comes  on  just  before  urination, 
increases  during  the  act  and  is  particularly  bad  at  the  end  and  disap- 
pears after  urination.  Occasionally  a  dull  ache  in  the  back.  No  pain  in 
rectum,  hips,  thighs,  legs,  groins  or  testicles.  No  hematuria,  no  calculus, 
no  loss  of  weight. 

Sexual  powers. — Has  had  no  erections  for  two  years. 

Examination. — The  patient  is  well  nourished  with  lips  of  good  color. 
Chest  and  abdomen  negative. 

Genitalia. — Negative. 

Rectal. — The  prostate  is  moderately  enlarged,  forming  a  globular  mass 
about  6  cm.  in  diameter.  It  is  smooth,  soft,  elastic,  no  nodules,  no  tender- 
ness. The  seminal  vesicles  are  soft,  there  is  no  perivesicular  induration, 
no  glands,  no  cords. 

Cystoscopic. — ^Catheter  passes  with  ease  and  withdraws  580  cc.  residual 
urine.  The  cystoscope  shows  very  little  enlargement  of  the  right  lateral 
lobe,  a  larger  left  lateral  lobe  and  a  pedunculated  intravesical  lobe  which 
springs  from  the  base  of  the  left  lateral  lobe,  in  other  words  a  left-sided 


453  ,  Hugh  II.  Young. 

median  lobe.  The  bladder  is  considerably  trabeculated.  There  is  no  stone 
present. 

Urinalysis. — Clear,  acid,  1010,  no  sugar,  a  trace  of  albumin,  a  few 
coarsely  granular  casts. 

Operation,  April  14,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  moderately  hypertrophied.  The  right 
was  quite  adherent  to  the  urethra  and  was  removed  in  two  pieces.  The 
left  was  removed  in  one  piece.  The  median  lobe  was  enucleated  through 
the  left  lateral  cavity,  it  was  moderately  enlarged.  The  urethra  was  torn, 
but  none  was  removed,  and  the  ejaculatory  ducts  were  preserved  intact. 
Closure  as  usual  with  double  tube  and  gauze  drainage.  The  patient  stood 
the  operation  well.     Pulse  at  end  75.     Infusion  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to 
101°  on  the  night  after  the  operation,  but  rapidly  fell  to  normal  and  re- 
mained so  after  the  second  day.  The  gauze  and  tubes  were  removed  on 
the  first  day.  He  was  up  in  a  chair  on  the  second  day.  Urine  passed 
through  the  anterior  urethra  on  the  16th  day,  and  he  was  discharged  on 
the  24th  day.  There  was  still  a  pin-point  fistula  in  the  perineum,  but  he 
voided  urine  easily  and  without  pain.  His  general  condition  was  excel- 
lent. 

June  7,  1906. — Letter.  The  perineal  wound  is  not  quite  closed,  and  a 
small  amount  of  urine  escapes  from  it.  I  am  free  from  pain  and  pass 
about  half  a  pint  of  urine  at  a  time,  three  or  four  times  during  the  day 
and  night.    My  general  health  is  good,  and  I  have  gained  in  weight. 

September  16,  1906. — The  perineal  fistula  has  never  closed  and  a  good 
deal  of  urine  escapes  through  it.  I  void  urine  five  or  six  times  during  the 
day  and  three  times  at  night,  the  largest  amount  at  one  time  being  one- 
half  to  one  pint.  I  do  not  have  erections.  My  general  health  is  good,  and 
I  have  gained  in  weight. 

Pathological  report. — ^The  specimen,  G.  U.  277,  consists  of  two  lateral 
lobes  of  about  equal  size  and  a  median  lobe  which  is  somewhat  smaller. 
The  total  weight  is  25  gm.  All  three  lobes  are  soft  and  elastic  in  con- 
sistency, the  surface  is  lobulated,  and  on  section  a  considerable  amount  of 
milky  fluid  exudes.  The  tissue  is  mostly  composed  of  lobules  within  many 
of  which  the  ducts  are  dilated. 

Microscopic  examination. — 'The  hypertrophy  is  a  lobulated  glandular  one. 
The  acini  vary  in  size,  some  presenting  a  considerable  degree  of  cystic  de- 
generation, while  others  are  normal.  Active  proliferation  seems  to  be  in 
progress  and  frequently  several  acini,  apparently  the  descendants  of  a 
single  acinus,  are  seen.  The  lumina  of  the  culs-de-sac  are  serrated,  due  to 
infolding  and  knuckles  of  epithelium  often  without  any  stroma  pedicle. 
The  stroma  apparently  contains  considerable  newly  formed  connecti-KC 
tissue,  and  the  connective  tissue  element  is  considerably  in  excess  of 
the  muscle.  The  arteries  seem  about  normal.  There  is  no  prostatitis 
present.  Although  in  this  prostate  there  are  a  number  of  areas  where 
proliferation  is  very  active  and  intraacinous  papillomatous  projections  are 
seen,  nowhere  is  any  evidence  of  carcinomatous  tendency  displayed. 


study  of  H5  Cases  of  Perineal  Prostatectomy.  453 

Case  137. — Age  31,  with  signs  of  obstruction  to  urination  since  early 
boyhood.  Small  inflammatory  prostate  with  obstructive  median  bar  and 
JfJtO  cc.  residual  urine.  Perineal  prostatectomy,  excision  of  median  bar. 
Cure.    Recent  case. 

No.  1278.— H.  W.  R.,  age  37,  single,  admitted  April  28,  1906. 

Complaint. — ''  Frequency  and  burning  on  urination." 

No  history  of  gonorrhoea  or  masturbation. 

The  patient  has  had  frequency  of  urination  since  his  earliest  recollec- 
tion, but  his  first  recollection  of  difficulty  of  urination  was  at  the  age  of 
eight  years.  At  that  time  he  remembers  that  during  recess  he  would  not 
be  able  to  urinate  like  the  other  boys,  and  often  could  not  void  at  all.  He 
had  no  eneuresis  as  a  child  nor  since.  He  has  never  had  gleet,  stricture 
nor  great  difiiculty  of  urination.  He  denies  syphilis  and  has  never  had 
symptoms  of  tabes.  At  the  age  of  17  he  entered  the  Naval  Academy,  but 
after  18  months  resigned  on  account  of  his  eyes  which  subsequently  got 
all  right  with  the  use  of  glasses.  One  day,  while  at  Annapolis,  he  acci- 
dentally discovered  a  lateral  hemiopia  which  has  recurred  at  intervals 
since  (now  about  20  times  in  all).  About  two  years  ago  he  took  a  course 
of  osteopathic  treatment,  and  a  tender  spot  was  discovered  between  the 
last  lumbar  and  first  sacral  vertebree  (this  tenderness  persists  and  the 
skin  is  red).  In  1905  he  began  to  have  burning  during  urination,  but 
this  was  relieved  by  internal  medicines.  He  consulted  his  present  phy- 
sician in  October,  1905,  who  writes  as  follows:  The  patient  complained 
of  difiicult  and  unduly  frequent  urination.  Examination  discloses  a  flabby 
prostate,  swollen  vesicles  and  hypersensitive  urethra,  but  no  urethral  dis- 
charge. A  catheter  withdrew  24  ounces  of  residual  urine,  since  then  cath- 
eterization has  shown  a  residuum  every  day  from  17  to  22  ounces.  Exam- 
ination by  a  neurologist  showed  no  lesion  of  the  nervous  system  and  an 
opthalmological  examination  was  also  negative.  When  catheterized  in  the 
recumbent  position  the  urine  flows  slowly  without  force,  requiring  press- 
ure on  the  abdomen  by  use  of  the  accessory  muscles  to  facilitate  emp- 
tying. 

Status  prwsens. — The  patient  voids  urine  10  or  12  times  during  the 
day,  catheterizes  himself  at  night  and  after  that  does  not  void  until  morn- 
ing. There  is  considerable  hesitation  when  starting  the  flow  of  urine  and 
the  stream  is  small  and  intermittent,  and  considerable  straining  is  neces- 
sary to  evacuate  the  bladder.  There  is  constantly  present  a  slight  burn- 
ing sensation  in  the  deep  urethra.  The  catheter  flnds  usually  from  16  to 
26  ounces  of  residual  urine.  After  catheterization  he  does  not  void  as  a 
rule  for  12  hours.  Occasionally  he  voids  shortly  after  catheterization.  He 
finds  that  the  difiiculty  of  starting  the  flow  of  urine  is  lessened  by  bending 
forward  and  flexing  flrst  one  thigh  and  then  the  other  against  the  abdo- 
men ("according  to  the  custom  of  dogs").  He  has  never  had  any  severe 
pains  in  the  abdomen. 

Sexual  powers  are  perfectly  normal.  He  is  nervous  about  himself,  but 
his  work  as  a  bookkeeper  is  entirely  satisfactory. 


454 


Hugh  H.  Young. 


Examination. — The  patient  is  a  healthy  looking  man  with  lips  of  good 
color.     Heart,  lungs  and  abdomen  negative. 

Genitalia. — ^There  is  no  urethral  discharge.  Testicles,  epididymes  and 
inguinal  regions  are  negative. 

Rectal. — The  prostate  is  a  little  larger  than  normal  and  slightly  irregu- 
lar. It  is  distinctly  but  moderately  indurated  in  places  and  quite  tender. 
The  seminal  vesicles  are  not  indurated  nor  enlarged,  and  there  is  no  in- 
tervesicular  induration.  There  are  no  adhesions  around  the  prostate  or 
vesicles  and  no  enlarged  glands.  The  rectum  is  soft  and  not  adherent. 
Palpation  above  the  prostate  in  the  region  of  the  bladder  is  negative.  The 
prostatic  secretion  is  composed  largely  of  pus  cells.  There  are  a  good 
many  lecithin  and   large  granule   cells  present,  but  no   spermatozoa  are 


Fig.  55.— Case  137. 


seen.  The  urine  is  cloudy  in  all  three  glasses,  slightly  alkaline,  1015,  mi- 
croscopically, pus  cells,  numerous  large  and  short  bacilli,  and  small,  round 
cocci  most  of  vphich  are  intracellular. 

Cystoscopic. — A  small  coude  catheter  meets  with  an  impassable  obstruc- 
tion in  the  deeper  portion  of  the  prostatic  urethra.  A  small  silver  cathe- 
ter also  fails  to  enter,  but  a  very  small  rubber  catheter  is  finally  intro- 
duced and  withdraws  440  cc.  residual  urine  (the  patient  had  just  voided 
150  cc).  The  cystoscope  enters  with  ease  and  shows  a  small,  but  definite 
enlargement  of  the  median  portion  of  the  prostate,  a  round  transverse 
median  fold  with  a  fairly  deep  sulcus  on  the  left.  This  bar  is  distinctly 
elevated  above  the  trigone  and  there  is  a  small  pouch  behind  it  into  which 
it  is  impossible  to  see  with  the  cystoscope.  The  right  lobe  of  the  prostate 
is  not  enlarged.  The  left  lobe  presents  a  small  globular  outgrowth  just 
at  the  prostatic  orifice  with  a  fairly  deep  sulcus  between  it  and  the  me- 
dian lobe,  as  shown  in  the  accompanying  diagram   (Fig.  55). 


study  of  145  Cases  of  Perineal  Prostatectomy. 


455 


Series  U,  with  the  beak  directed  upward,  shows  that  this  lobe  comes 
prominently  into  view  when  the  handle  is  gradually  elevated.  In  Series  D, 
with  the  beak  directed  downward  and  the  handle  depressed,  a  somewhat 
pointed  median  bar  which  covers  most  of  the  trigone  is  seen.  On  elevating 
the  handle  more  of  the  trigone  comes  into  view,  but  the  rounded  bar  is 
very  evident.  The  ureteral  ridges  are  hypertrophied.  The  oriiices  look  fairly 
normal.  The  bladder  is  considerably  trabeculated,  thrown  into  irregular 
folds  and  inflamed,  and  shows  evidence  of  long  standing  obstruction.  No 
diverticula  are  seen  after  a  careful  search,  but  owing  to  hemorrhage  it  is 
impossible  to  get  a  very  good  view.  No  calculus  seen.  With  finger  in  rec- 
tum and  cystoscope  in  urethra  the  beak  is  easily  felt,  and  there  is  a  slight 
but  definite  increase  in  the  median  portion  of  the  prostate. 

Remark. — ^The  cystoscopic  examination  seems  to  furnish  undoubted  evi- 
dence of  obstruction  at  the  prostatic  orifice. 


Fig.  56. — Small  median  and  lateral  lobes  from  man,  age  37. 


Operation,  May  2,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  posterior  surface  of  the  prostate  was  no  larger  than  nor- 
mal, smooth,  regular  and  only  slightly  indurated.  Bilateral  capsular  in- 
cisions were  made  a  litte  more  distant  from  each  other  than  usual.  The 
lateral  lobes,  which  were  no  larger  than  normal,  were  excised,  the  sharp 
periosteal  elevator  being  employed.  It  was  impossible,  with  the  tractor, 
to  present  the  median  portion  of  the  prostate  into  either  of  the  lateral 
cavities,  and  the  left  lateral  wall  of  the  urethra  had  to  be  divided  before 
the  finger  could  be  introduced.  The  prostatic  orifice  was  surrounded  by  a 
very  firm,  hard  ring  which  was  difficult  to  break  with  the  finger.  Exami- 
nation showed  a  very  small  median  fold  and  a  slight  redundancy  or  fold 
of  tissue  along  the  left  lateral  margin.  With  the  aid  of  the  sharp  perios- 
teal elevator  and  with  scissors,  both  of  these  were  excised  along  with  a 
portion  of  the  mucous  membrane,  thus  leaving  a  large  orifice  (Fig.  56, 
in  which  the  fragments  are  placed  together).  The  floor  of  the  urethra 
and  ejaculatory  ducts  and  right  lateral  wall  of  the  urethra  were  undis- 
turbed. The  wound  was  closed  as  usual  with  double  tube  drainage  for  the 
bladder,  light  packs  for  the  lateral  cavities,  approximation  of  the  levator 
muscles  with  a  single  suture  of  catgut  and  partial  closure  of  the  cutaneous 
wound  with  catgut.  Infusion  and  continuous  irrigation  on  return  to  the 
ward.    Pulse  at  the  end  88. 


456  Hugh  H.  Young. 

Convalescence. — The  patient  reacted  well,  but  for  three  days  the  tempera- 
ture varied  between  100°  and  102°  and  one  day  reached  104°.  After  that 
it  was  practically  normal.  The  irrigation  was  discontinued  after  12  hours, 
the  tubes  and  gauze  removed  on  the  day  after  the  operation.  There  was 
some  bleeding  and  discharge  of  clots  of  blood  from  the  perineal  wound  af- 
ter removal  of  the  gauze,  but  the  patient  suffered  no  pain  and  was  up  on 
the  third  day.  On  the  fourth  day  after  the  operation  urine  began  to  flow 
through  the  urethra  and  the  sutured  wound  appeared  well  healed,  but  on 
the  seventh  day  swelling,  redness  and  tenderness  appeared  at  the  lower 
end  of  the  left  branch  of  the  V,  and  considerable  pus  was  evacuated 
through  an  opening  which  was  made  in  this  portion  of  the  wound.  After 
that  there  was  a  moderate  amount  of  suppuration  for  two  weeks,  but  on 
the  29th  day  the  wound  looked  healthy  and  two  days  later  urine  came  en- 
tirely through  the  penis.  Urinary  control  was  established  during  the 
third  week  and  before  the  patient  left  the  hospital  he  was  able  to  retain 
urine  for  11  hours  at  night,  voided  freely,  in  a  large  stream,  with  perfect 
control  and  without  pain.  He  was  discharged  from  the  hospital  on  the 
33d  day  in  excellent  condition. 

September  14,  1906. — The  perineal  fistula  closed  87  days  after  the  op- 
eration. I  void  urine  naturallj',  in  a  good  stream  six  times  during  the 
day  and  not  at  all  during  the  night,  as  much  as  650  cc.  at  a  time  and 
without  pain.  Sexual  intercourse  is  entirely  satisfactory,  in  fact  more 
normal  than  before  operation.  My  general  health  is  good.  I  have  gained 
10  pounds  and  consider  myself  cured. 

Pathological  report. — The  specimen,  G.  U.  283,  consists  of  six  small 
pieces  of  prostatic  tissue,  weighing  in  all  about  10  gm.  The  left  lateral 
lobe  was  removed  in  two  pieces,  the  largest  being  2  x  2.5  x  1.5  cm.  and  the 
smallest  piece  being  a  mere  tag  of  tissue,  they  both  weigh  about  4  gm. 
The  right  lobe  was  also  removed  in  two  pieces,  and  weighs  the  same  as 
the  left.  On  section  the  prostatic  tissue  of  the  lateral  lobes  does  not  re- 
semble at  all  a  hypertrophy.  There  are  no  lobules  seen,  the  surface  is 
homogeneous,  somewhat  brownish  in  color,  and  on  close  examination  is 
finely  granular.  Some  small  hemorrhagic  points  noted  here  and  there. 
The  consistency  is  firm,  but  elastic.  The  tissue  resembles  much  that  of 
the  normal  prostate.  The  median  bar  was  removed  in  two  pieces  and 
weighs  about  2  gm.  Its  consistency  is  distinctly  firmer  than  the  lateral 
lobes,  on  section  the  surface  is  rather  dry,  translucent,  and  distinct  white 
fibrous  trabeculge  interlacing  in  various  directions  through  the  prostatic 
tissue  are  seen. 

Microscopic  examination. — A  section  from  the  left  lateral  lobe.  The 
acini  are  for  the  most  part  dilated  and  many  of  them  show  the  serrated 
margin  and  papillary  projections  which  are  seen  in  the  hypertrophied 
prostate.  This  condition  of  the  acini,  however,  is  limited  to  a  small  por- 
tion of  the  section.  In  other  portions  the  acini  are  only  occasionally  di- 
lated, but  there  is  present  quite  an  extensive  prostatitis.  Some  of  the 
acini  are  filled  wih  proliferating  and  desquamated  epithelial  cells  and 
leucocytes  and  the  infiltration  extends  well  out  into  the  interstitial  tis- 


study  of  1J/-5  Cases  of  Perineal  Prostatectomy.  457 

sue,  being  most  marked  immediately  surrounding  the  acini.  Some  gland 
groups  show  considerable  periacinous  sclerosis.  The  interstitial  stroma 
is  infiltrated  in  rather  extersive  areas,  but  at  times  a  normal  stroma  is 
seen  in  between  inflamed  glandular  groups. 

A  section  from  the  deep  portion  of  the  left  lateral  is  almost  entirely 
composed  of  muscle  which  has  probably  been  removed  from  about  the 
vesical  orifice.  "Within  this  section  some  areas  of  round  cell  infiltration 
are  noted,  especially  around  the  blood  vessels. 

A  section  from  the  right  lobe  shows  a  picture  very  similar  to  the  left 
lateral  areas  of  well  marked  prostatitis  and  areas  with  acini  similar  to 
those  of  prostatic  hypertrophy  being  found. 

A  section  from  the  median  bar  shows  a  condition  similar  to  the  lateral 
lobes.  Many  of  the  acini  are  dilated,  have  serrated  margins  and  papillary 
projections,  and  suggest  that  some  glandular  proliferation  was  in  pro- 
gress. In  other  areas,  however,  the  acini  are  compressed  and  are  involved 
by  inflammatory  processes. 

I 

Case  138. — Considerable  enlargement  of  right  and  median  lohes.     Small 

left  lateral.     Nocturnal  incontinence  the  only  symptom. 

S.  No.  19,071.     S.  McM.,  age  57,  married,  admitted  April  25,  1906. 

Complaint. — "  Inability  to  hold  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  six  months  ago  with  dribbling  of  urine  when  in 
the  recumbent  posture.  He  first  noticed  that  the  bed  was  wet  in  the  morn- 
ing. During  the  day  he  urinated  at  intervals  without  pain  and  there 
was  no  dribbling,  and  at  night  he  slept  all  the  night  without  rising,  but 
would  invariably  find  the  bed  wet.  The  disease  has  been  unchanged  since 
the  beginning.  There  has  never  been  any  frequency  during  the  day,  no 
pain,  no  difiiculty  in  urination,  and  his  general  health  has  remained  good. 

Status  prcesens. — Incontinence  at  night.  No  increased  frequency,  no 
difiiculty,  no  pain  or  hemorrhage.  Sleeps  all  night  without  voiding  urine 
and  finds  the  bed  wet  in  the  morning.  His  only  complaint  is  inconti- 
nence. His  general  health  is  good.  Has  had  no  nausea  or  vomiting;  has 
not  lost  weight.     Sexual  powers  normal. 

Examination. — The  patient  is  a  well  nourished  man  with  lips  slightly 
cynotic.  The  chest  is  barrel-shaped.  Lungs  emphysematous.  The  heart 
sounds  clear  but  distant. 

Abdomen. — A  greatly  distended  bladder  can  be  felt  reaching  half  way 
between  the  umbilicus  and  the  symphysis.  There  is  a  small  complete 
hernia  on  the  right  side  and  a  partially  descended  testicle.  On  the  left 
side  there  is  also  a  definite  but  small  hernia. 

Rectal. — (The  prostate  is  considerably  enlarged  forming  a  smooth  lobu- 
lar mass  about  the  size  of  a  small  orange,  firm  but  uniform  in  consist- 
ence. The  seminal  vesicles  are  not  palpable.  No  enlarged  glands,  rectal 
mucosa  soft. 

Cystoscopic. — A  catheter  passes  with  ease  and  withdraws  890  cc.  resid- 
ual urine.     The  cystoscope  shows  a  large  median  lobe,  a  moderate  intra- 


458  Hugh  H.  Young. 

vesical  enlargement  of  right  lateral  lobe.  It  was  impossible  to  get  the  cys- 
toscope  into  the  cleft  to  the  left  of  the  middle  lobe,  owing  to  the  height 
of  the  median  enlargement.  The  bladder  is  trabeculated  with  numerous 
cellules  and  pouches,  but  no  diverticula.  The  ureteral  orifices  were  hidden 
behind  median  portion.  No  stone  present.  With  finger  in  rectum  and  cys- 
toscope  in  urethra  the  beak  cannot  be  felt  and  the  median  enlargement  is 
considerable. 

Urinalysis. — €loudy,  acid,  1010,  no  sugar,  albumin  a  trace,  pus  cells  in 
large  number. 

Preliminary  treatment. — Catheterization  three  times  daily.  Water  in 
abundance,  urotropin.  Over  600  cc.  of  urine  was  generally  withdrawn. 
The  patient  was  able  to  void  only  small  amounts,  and  about  nine  hours 
after  catheterization  he   began  to   dribble. 

May  7,  1906. — Operation.  Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  right  lateral  lobe  was  considerably  enlarged  and  enu- 
cleated in  one  piece.  The  left  lobe  was  about  half  the  size  of  the  right 
and  firmer,  but  distinctly  elastic.  The  median  lobe  was  enucleated  through 
one  of  the  lateral  cavities,  and  was  considerably  enlarged.  A  small  tear 
was  made  in  the  mucous  membrane  of  the  urethra  and  a  small  area  of 
mucous  membrane  attached  to  the  summit  of  the  median  lobe  was  re- 
moved. Examination  showed  no  further  enlargement.  The  wound  was 
closed  as  usual  with  double  tube  drainage,  light  packs  for  the  lateral  cavi- 
ties. Infusion  and  continuous  irrigation  on  return  to  the  ward.  The  pa- 
tient stood  the  operation  well.     Pulse  at  the  end  100. 

Convalescence. — 'The  patient  reacted  well  from  the  operation.  The 
temperature  rose  to  101°  on  the  night  after  the  operation,  but  it  was  nor- 
mal on  the  next  and  remained  so  until  the  10th  day  when  he  had  a  tem- 
perature of  101.5°  lasting  for  three  days.  The  tubes  and  gauze  were  re- 
moved on  the  day  after  the  operation  and  the  patient  was  up  in  a  chair 
on  the  second  day  after  the  operation.  On  the  tenth  day  there  was  a 
slight  cough  and  a  few  crackles  were  heard  over  the  right  lung,  associ- 
ated with  pain  and  a  temperature  of  101.5°. 

May  25,  1906. — For  10  days  the  urine  leaked  continually  through  the 
perineum.  After  the  10th  day  he  had  control  and  voided  urine  at  inter- 
vals, at  first  one  hour,  on  the  18th  day  three  hours,  and  without  pain. 

September  13,  1906. — Letter.  The  perineal  wound  has  been  closed  since 
about  four  weeks  after  the  operation.  Urine  is  voided  naturally  four 
times  during  the  day  and  once  at  night,  in  normal  amounts  and  without 
pain.  Sexual  intercourse  is  not  entirely  satisfactory,  there  being  no  emis- 
sion as  yet.     I  have  gained  30  pounds  and  am  cured. 

Pathological  report.— -The  specimen,  G.  U.  287,  consists  of  three  pieces 
representing  the  two  laterals  and  the  median  lobe.  The  left  lobe  is  a 
rounded  mass  5x4x3  cm.,  the  surface  is  lobulated,  consistency  firm,  but 
elastic.  On  section  the  tissue  is  rather  white,  is  not  succulent,  and  the 
surface  is  indistinctly  lobulated.  The  left  lobe  is  a  mass  about  half  the 
size  of  the  right,  its  consistency  is  firm,  but  elastic,  and  it  is  composed  of 
numerous  spheroids  which  seem  to  be  largely  made  up  of  stroma.     The 


study  of  145  Cases  of  Perineal  Prostatectomy.  459 

median  lobe  is  a  mass  4x2x2  cm.  and  on  its  upper  surface  is  a  fair- 
sized  piece  of  mucous  membrane.  It  has  the  same  general  character  as 
both  of  the  lateral  lobes. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  glandular 
one.  The  acini  are  for  the  most  part  dilated,  while  here  and  there  one  has 
undergone  cystic  degeneration.  About  the  periphery  of  these  glandular 
lobules  the  acini  are  compressed  and  elongated.  Numerous  areas  of  pros- 
tatitis are  noted.  The  stroma  contains  a  large  amount  of  muscle.  The 
arteries  show  no  thickening. 

Case  139. — Considerable  enlargement  of  the  lateral  lobes,  small  median 
lobe.  Very  iveak  old  man.  Convalescence  satisfactory.  Left  hospital  in 
good  condition.    Recent  case. 

No.  1285.     S.  C.  C,  age  71,  married,  admitted  May  5,  1906. 

Coviplaint. — "  Prostatic  obstruction,  catheterism,  pain." 

The  patient  had  gonorrhoea  as  a  boy;   no  complications. 

Ten  years  ago  he  had  sudden  complete  retention  of  urine  which  was 
relieved  by  medicine.  During  the  next  eight  years  he  remained  perfectly 
well.  Two  years  ago  he  began  to  have  difficulty  of  urination  and  a  grad- 
ual increasing  frequency,  and  in  a  short  time  pain  in  the  testicles.  The 
frequency  and  difficulty  of  urination  gradually  increased  until  five  weeks 
ago  when  he  began  the  use  of  the  catheter.  Since  then  he  has  catheter- 
ized  himself  from  one  to  three  times  daily,  but  has  always  been  able  to 
void  a  small  amount  of  urine  naturally.  For  the  past  year  he  has  had  a 
bearing  down  feeling  in  the  rectum,  and  constipation.  He  has  had  no  hema- 
turia, except  after  the  introduction  of  a  catheter  and  has  never  passed  a 
stone.  He  has  had  no  pain  in  the  back,  thighs  or  groins,  and  only  a  mod- 
erate amount  of  pain  in  the  bladder,  except  when  the  bladder  bec'omes 
full  and  urination  is  difficult. 

Status  pra-sens. — ^Urination  about  every  two  hours,  stream  small,  urina- 
tion diflScult,  often  accompanied  by  considerable  straining.  The  patient 
catheterizes  himself  two  or  three  times  a  day  and  does  obtain  some  re- 
lief, but  soon  after  catheterization  has  to  void  again.  He  has  lost  consid- 
erable weight  and  is  very  weak. 

Sexnal  powers. — ^Erections  and  intercourse  satisfactory  up  to  one  month 
ago. 

Examination. — The  patient  is  emaciated  and  a  very  weak  looking  man. 
The  mucous  membranes  are  pale,  the  lungs  are  hyperresonant,  the  breath 
sounds  are  loud  and  expiration  is  prolonged.  The  heart  is  slightly  en- 
larged. The  first  sound  at  the  apex  is  muffled.  The  pulse  is  regular,  of 
good  tension.  There  is  only  moderate  arteriosclerosis.  Abdomen  nega- 
tive. 

Genitalia. — -Varicose  veins  on  left  side,  induration  of  right  globus  minor 
and  slight  hydrocele. 

Rectal. — 'The  prostate  is  considerably  enlarged,  smooth,  somewhat  ir- 
regular in  contour,  the  left  lobe  being  larger  than  the  right,  and  some- 
what lobulated.     The  consistence  is  generally  elastic,  but  somewhat  firm. 


460  Hugh  H.  Young. 

and  on  the  right  side  near  the  apex  there  is  a  nodule  about  the  size  of 
the  finger  tip  of  stony  hardness,  and  extending  laterally  from  this  is  an 
Indurated  band  running  out  to  the  pelvic  wall.  The  membranous  urethra 
is  soft,  and  there  is  no  induration  in  this  region.  The  regions  of  the 
seminal  vesicles  are  negative  and  there  is  no  intervesicular  mass.  No 
enlarged  glands  are  present.     The  rectal  mucosa  is  soft  and  movable. 

Cystoscoplc. — The  patient  voided  30  cc.  of  urine.  A  coude  catheter 
passes  with  ease  and  finds  300  cc.  residual  urine.  The  bladder  is  some- 
what contracted.  The  cystoscope  shows  a  slight  enlargement  of  the  left 
lateral  lobe,  a  considerable  enlargement  of  the  right  lateral  lobe  with  a 
small  thin  transverse  bar  in  the  median  portion  of  the  prostate.  The 
bladder  is  trabeculated,  inflamed,  and  external  to  the  urethral  orifice  on 
each  side  a  small  diverticulum  is  seen.  There  is  no  stone  present.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  is  easily  felt.  There 
is  only  very  slight  increase  in  the  median  portion  of  the  prostate  and  no 
subtrigonal  thickening. 

Urinalysis. — Cloudy,  acid,  1013,  albumin  a  trace,  no  sugar,  no  casts. 
Microscopically,  pus  cells,  red  blood  corpuscles. 

Operation,  May  9,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  left  lobe  was  moderately  hypertrophied  and  removed  in 
one  piece.  The  right  lateral  lobe  was  considerably  enlarged,  a  globular 
intravesical  projection  being  present.  It  was  easily  removed  in  one  piece. 
A  small  median  bar  was  delivered  into  the  left  lateral  cavity  and  re- 
moved, the  urethra  being  torn  but  none  removed.  Examination  with  the 
finger  showed  no  remaining  prostatic  enlargement.  The  ejaculatory  ducts 
were  preserved  intact.  The  wound  was  closed  as  usual  with  double  tube 
drainage,  light  packs  for  the  lateral  cavities,  approximation  of  the  leva- 
tors with  a  single  suture  of  catgut  and  partial  closure  of  the  cutaneous 
wound  with  interrupted  sutures  of  catgut.  Infusion  on  the  table,  con- 
tinuous irrigation  on  return  to  the  ward.  The  patient  stood  the  operation 
well.    Pulse  at  the  end  100. 

Convalescence. — <The  patient  reacted  well.  Six  hours  after  the  operation 
the  scrotum  was  found  distended  to  the  size  of  a  child's  head  with  ex- 
travasated  fluid.  Examination  showed  that  the  exit  tube  was  not  draining 
well,  the  wound  was  sewed  too  tightly  around  the  catheters  and  fluid  es- 
caping from  the  bladder  had  extravasated  beneath  the  skin  into  the  scro- 
tum. By  making  pressure  it  was  found  possible  to  evacuate  the  extravasa- 
tion through  the  perineal  wound,  though  owing  to  the  fear  of  infection 
it  was  thought  best  to  make  two  small  incisions  for  the  insertion  of  small 
gauze  drains. 

For  six  days  the  patient  had  pyrexia  which  reached  103°  on  the  fifth 
day,  but  after  that  it  was  normal.  He  was  quite  weak  for  seven  or  eight 
days,  and  on  the  fourth  day  he  was  given  an  infusion.  Although  weak 
he  was  up  in  a  wheel-chair  every  day  and  during  the  second  'week  im- 
proved rapidly.  On  the  22d  day  most  of  the  urine  was  coming  through 
the  urethra.  The  patient  was  discharged  on  the  30th  day  after  the  opera- 
tion.    A    minute    perineal    fistula    was    present,    through    which    a    small 


study  of  IJfO  Cases  of  Perineal  Prostatectomy.  461 

amount  of  urine  escaped.  The  patient  had  become  quite  strong,  was  en- 
tirely comfortable,  voided  urine  without  pain  and  insisted  on  going  home. 

September  14,  1906. — Letter.  The  perineal  fistula  healed  94  days  after 
the  operation.  Urine  is  voided  naturally  at  intervals  of  three  or  four 
hours,  about  a  pint  at  a  time.  I  have  no  pain,  no  erections.  Have  gained 
20  pounds  in  weight. 

Pathological  report. — 'The  specimen,  G.  U.  291,  consists  of  two  pieces,  the 
left  lobe  and  a  portion  which  represents  the  vesical  part  removed  in  one 
piece.  The  mass  measures  6x5x3  cm.  The  intravesical  portion  is  con- 
nected with  the  main  mass  by  a  narrow  neck  of  tissue.  The  surface  is 
lobulated,  consistency  soft.  On  section  the  tissue  is  composed  of  numer- 
ous lobules,  irregular  in  shape  and  of  varying  size.  In  one  of  the  lobules 
the  ducts  are  very  much  dilated,  but  the  others  are  smooth,  firm  and  seem 
to  contain  a  large  proportion  of  stroma.  The  right  lobe  is  a  somewhat 
rounded  mass,  much  smaller  than  the  left,  and  measures  2.5  x  2  x  2  cm. 
The  surface  is  lobulated  and  the  consistency  is  soft.  On  section  it  is  en- 
tirely composed  of  spheroids  of  different  sizes  and  shapes,  with  but  little 
interspheroidal  tissue.  Numerous  areas  of  dilated  ducts  are  to  be  seen. 
About  the  lobe  as  a  whole  is  a  fairly  well  developed  capsule. 

Microscopic  examination. — The  hypertrophy  is  a  lobulated  glandular  one. 
The  acini  are  dilated,  show  numerous  intraacinous  papillary  projections. 
In  some  acini  there  is  capillary  looping  of  the  epithelium  present.  In 
one  area  the  acini  are  very  much  dilated,  and  growing  out  from  the 
periphery  on  all  sides  are  slender  strands  of  epithelium  which  appar- 
ently have  very  little  supporting  stroma.  The  epithelial  projections  by 
their  union  form  irregular  shaped  spaces  within  the  acini.  The  epithelium 
is  rather  pale,  of  a  high  columnar  type,  and  there  is  no  tendency  to  infil- 
trate in  the  stroma.  Some  areas  of  chronic  infiammation  about  the  blood 
vessels.  The  blood  vessels  seem  normal.  The  stroma  is  rather  loose  in 
character  and  contains  a  moderate  amount  of  muscle. 

Case  140. — Moderate  enlargement  of  median  and  lateral  lohes  of  the 
prostate  with  induration  of  prostate  and  vesicles  and  pelvic  lymph  glands. 
Large  vesical  calculus.  Perineal  prostatectomy  and  lithotomy.  Cure.  Re- 
ceyit  case. 

No.  1287.  A.  L.,  age  58,  married,  admitted  May  3,  1906. 

Complaint. — "  Frequency  of  urination  and  pain." 

There  is  no  history  of  gonorrhoea. 

Present  illness  began  one  and  one-half  years  ago  with  burning  during 
urination,  frequency  and  difficulty.  One  month  later  he  had  hematuria. 
The  course  of  the  disease  has  been  marked  by  the  gradual  increase  in  the 
frequency  and  difficulty  and  pain.  He  has  never  had  complete  retention 
of  urine  nor  been  catheterized. 

Status  pra^sens. — Urination  every  hour  night  and  day,  accompanied  by 
a  burning  pain  in  the  urethra  and  a  sharp,  severe  pain  at  the  end  of  urina- 
tion radiating  to  the  end  of  the  penis.  He  has  had  no  pain  in  the  back, 
but  occasionally  a  slight  pain  in  the  outer  side  of  both  thighs.    Hematuria 


462  Hugh  H.  Young. 

has  beeu  present  occasionally.  He  has  grown  weaker,  but  has  not  lost 
much  in  weight.     His  sexual  powers  are  still  present. 

E xa7ninati07i. —^The  patient  is  a  fairly  strong  looking  man  with  lips  of 
good  color.    The  heart,  lungs  and  abdomen  are  negative. 

Genitalia. — Negative. 

Rectal.^The  prostate  is  not  greatly  enlarged,  it  is  smooth,  moderately 
indurated,  but  not  of  stony  hardness.  The  lateral  lobes  are  uniformly 
large,  there  are  no  nodules,  no  areas  of  tenderness.  The  right  seminal 
vesicle  is  not  definitely  enlarged,  but  several  hard  cords  are  felt  in  this 
region  and  three  or  four  enlarged,  somewhat  indurated  glands  are  found 
at  the  outer  end  of  the  vesicle  along  the  pelvic  wall.  The  left  seminal 
vesicle  is  also  not  much  enlarged,  but  several  cords  and  a  small  mass  of 
glands  are  also  discovered  on  this  side.  In  the  sacral  fossa  there  is  a 
small  mass  suggestive  of  glands  felt. 

Cystoscopic. — The  patient  voided  about  100  cc.  urine.  A  coude  catheter 
was  then  passed  with  ease  and  100  cc.  withdrawn.  The  bladder  capacity 
is  250  cc.  The  cystoscope  shows  very  little  intravesical  enlargement  oi: 
the  lateral  lobes.  There  is  a  small  but  definite  rounded  median  lobe  with 
a  shallow  sulcus  on  each  side.  Behind  this  a  large,  smooth,  oval  calculus, 
free  in  the  bladder,  is  seen.  The  bladder  is  considerably  inflamed  and 
trabeculated,  but  no  diverticula  are  seen.  With  finger  in  the  rectum  and 
cystoscope  in  urethra,  no  increase  in  the  subtrigonal  tissues  is  made  out 
and  the  median  portion  of  the  prostate  is  definitely,  but  not  very  greatly 
hypertrophied. 

Urinalysis. — 'Cloudy,  acid,  1012,  no  sugar,  albumin  in  small  amount. 
Microscopically,  pus  cells  and  a  few  red  blood  corpuscles. 

Operation,  May  9,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Removal  of  a  large  vesical  calculus  through  the  perineum. 
The  lateral  lobes  were  moderately  enlarged,  and  each  was  removed  in 
one  piece,  they  were  quite  adherent  and  stripped  with  some  difficulty.  A 
small  median  lobe  was  delivered  into  the  right  lateral  cavity  and  enu- 
cleated, a  small  tear  being  made  in  the  urethra  which  was  then  split  open 
along  its  lateral  wall.  The  neck  of  the  bladder  was  then  dilated  with  for- 
ceps, a  stone  forceps  inserted  and  a  large  oval  calculus  easily  removed, 
without  division  of  the  muscular  fibers  at  the  neck  of  the  bladder.  Ex- 
amination with  the  finger  showed  no  remaining  prostatic  enlargement, 
no  calculus.  The  floor  of  the  urethra  and  ejaculatory  ducts  were  preserved 
intact.  The  wound  was  closed  as  usual  with  double  tubes  for  the  blad- 
der, light  packs  for  the  lateral  cavities,  approximation  of  the  levators 
with  single  sutures  of  catgut,  and  partial  closure  of  the  cutaneous  wound 
with  catgut.  The  patient  stood  the  operation  well.  Infusion  and  contin- 
uous irrigation  on  return  to  the  ward.     Pulse  at  the  end  85. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
100.8°  on  the  day  after  the  operation,  after  that  it  was  normal.  The  gauze 
was  removed  on  the  day  after  the  operation  and  the  tubes  on  the  next 
day,  and  the  patient  was  then  gotten  out  of  bed.  Urine  came  through  the 
anterior  urethra  during  the  second  week.     The  fistula  closed  on  the  14th 


study  of  lJt5  Cases  of  Perineal  Prostatectomy.  463 

day,  and  the  patient  was  discharged  on  the  17th  day  after  the  operation 
in  excellent  condition,  voiding  urine  freely  without  pain. 

June  16,  1906. — -The  patient  returns  for  examination.  He  voids  urine 
naturally  in  a  large  stream  and  without  pain  at  intervals  of  four  hours 
during  the  night,  but  more  frequently  during  the  day.  His  general  health 
is  excellent. 

September  12,  1906. — Letter.  I  void  urine  from  6  to  10  times  during 
the  day  and  2  or  3  times  at  night  in  amounts  varying  from  1  to  8  ounces. 
Have  pain  in  the  urethra  when  weather  changes.  No  erections.  General 
health  good.     Am  cured  with  exception  of  slight  pain. 

Pathological  report. — 'The  specimen,  G.  U.  289,  consists  of  three  pieces 
of  tissue  representing  the  two  lateral  lobes  and  the  median  bar,  total 
weight  about  11  gm.  The  left  lobe  is  a  somewhat  rounded  mass  2  x  2  x  1.5 
cm.  The  consistency  is  rather  firm  and  the  surface  shows  no  lobulation; 
the  cut  surface,  however,  shows  several  large  lobules  which  are  smooth, 
and  show  no  dilated  acini.  The  right  lobe  is  less  than  half  the  size  of  the 
left  and  is  somewhat  irregular.  Its  cut  surface  is  homogeneous,  and 
there  is  no  formation  of  spheroids.  The  median  bar  weighs  about  2  gm. 
and  measures  2.5  x  1  x  .5  cm.  Its  consistence  is  firm  and  elastic,  it  shows 
no  tendency  to  the  formation  of  spheroids,  but  its  cut  surface  has  a  rather 
grayish  homogeneous  appearance  with  a  few  dilated  ducts  here  and  there. 
The  gross  picture  in  this  median  bar  strongly  suggests  chronic  prostatitis. 
A  smooth  calculus,  oblong,  flat,  and  measuring  4  x  3  x  1.5  cm.  was  removed. 
Ejaculatory  ducts  not  found  in  specimen. 

Microscopic  examination. — Sections  from  the  left  lateral  lobe  show  a 
tissue  which  is  largely  composed  of  stroma,  although  here  and  there  areas 
containing  aggregations  of  acini  are  encountered.  The  acini  within  these 
areas  are  dilated  and  show  numerous  intraacinous  papillary  projections; 
some  areas  of  chronic  prostatitis  are  seen.  The  blood  vessels  are  only 
slightly  thickened  and  the  stroma  seems  mostly  composed  of  fibrous 
tissue. 

In  the  median  bar  glandular  areas  alternate  with  areas  in  which  the 
stroma  predominates,  but  there  is  present  a  much  more  extensive  prosta- 
titis than  in  either  of  the  lateral  lobes.  In  areas  this  had  led  to  consid- 
erable fibrous  tissue  formation. 

Case  141. — 'Small  globular  median  lohe.  No  lateral  enlargement.  Com- 
plete retention  of  urine.  Catheter  life  two  years.  Prostatectomy :  Removal 
of  sw.all  lateral  and  pedunculated  median  lobe.  Persistence  of  obstruc- 
tion. Second  operation  on  eighth  day.  Excision  of  median  portion  of 
prostate.  Rapid  convalescence.  Wound  closed  on  20th  day  after  first 
operation.    Recent  case. 

No.  1292.     H.  H.  L.,  60,  married,  admitted  May  14,  1906. 

Complaint. — ."  Prostatic  obstruction.     Catheterism." 

Gonorrhoea  in  youth  followed  by  slight  stricture,  no  gleet. 

Present  illness  began  five  years  ago  with  slight  increased  frequency  of 
urination.  About  four  months  later  urination  suddenly  became  very  dif- 
Vol.  XIV.— 30. 


464  Hugli  H.  Young. 

ficult  and  he  was  catheterized,  about  eight  ounces  residual  urine  being 
withdrawn.  During  the  next  two  years  was  catheterized  once  a  day  at 
bedtime,  voided  frequently  and  in  driblets  during  the  day.  During  the 
past  two  years  retention  of  urine  has  been  complete  and  the  patient  has 
catheterized  himself  about  five  times  a  day.  During  this  time  he  has  had 
very  little  vesical  disturbance,  and  has  been  treated  by  Dr.  Smith  by 
prostatic  massage  three  times  a  week.  Under  this  treatment  the  size  of 
the  prostate  has  been  reduced  one-third  in  size,  but  retention  of  urine  is 
still  complete.  Has  had  two  attacks  of  epididymitis.  The  patient  has  had 
two  Bottini  operations,  single  posterior  cut  each  time  without  success. 

Status  prcesens.— 'The  patient  catheterizes  himself  about  five  times  a  day, 
using  a  soft  rubber  catheter  and  withdrawing  from  eight  to  eleven  ounces 
of  urine.  Is  never  able  to  pass  urine  naturally;  no  hematuria,  no  calcu- 
lus, no  pain  unless  the  bladder  becomes  too  full.  Occasionally  there  is  a 
slight  bloody  urethral  discharge  associated  with  tenderness  in  the  pros- 
tate. He  has  gained  in  weight.  No  pain  in  back,  thighs,  legs,  groins,  or 
testicles. 

Sexual  powers.— 'Patient  still  has  erections  and  sexual  desire,  but  has 
not  had  intercourse  for  several  months. 

Examination. — The  patient  is  a  sturdy  looking  man  with  lips  of  good 
color.  Pulse  regular,  no  arteriosclerosis.  Lungs  are  normal,  heart  not 
enlarged  and  there  are  no  murmurs,  but  the  valvular  sounds  are  slightly 
muflaed.     Abdomen  is  negative. 

Genitalia. — ^Slight  induration  of  right  epididymis. 

Rectal.— ^Prostate  is  very  little  larger  than  normal.  It  is  smooth,  slightly 
indurated,  not  tender.  The  base  of  each  seminal  vesicle  is  slightly  indu- 
rated, particularly  the  left.  There  is  no  intervesicular  mass.  The  mem- 
branous urethra  is  soft.  There  are  slight  indurations  along  the  left  lobe 
of  the  prostate  and  left  vesicle.  The  induration  of  the  vesicles  is  of  mod- 
erate degree. 

Prostatic  secretion  contains  numerous  actively  motile  spermatozoa,  pus 
cells,  large  and  small  granular  cells,  very  few  lecithins.  The  urethral 
discharge  is  composed  of  pus  and  epithelial  cells,  no  bacteria. 

Cystoscopy  performed  August  15,  1905.  The  catheter  encounters  a  stric- 
ture of  large  caliber  four  and  three-quarters  inches  from  the  meatus.  No. 
24-F.  bulbous  bougie  passes  with  ease.  A  coude  catheter  withdraws  about 
300  cc.  urine.  Retention  of  urine  is  complete.  The  cystoscope  shows  very 
little  enlargement  of  the  lateral  lobes  and  a  definite,  small,  rounded  me- 
dian lobe  with  a  sulcus  on  each  side.  A  small  depression  in  the  top  of 
this  is  present,  probably  the  site  of  the  Bottini  incision.  The  bladder  is 
only  slightly  trabeculated,  no  diverticula,  no  stone  present. 

Urinalysis. — 1028,  slightly  acid,  trace  of  albumin,  no  sugar,  no  casts 
seen,  moderate  amount  of  pus,  much  phosphates,  many  bacilli. 

May  16,  1906.  Operation. — ^Ether.  Perineal  protatectomy  by  the  usual 
technique.  The  lateral  lobes  seemed  little,  if  at  all,  enlarged,  but  were 
easily  stripped  out  and  were  about  2  or  3  cm.  in  diameter.     In  removing 


Study  of  IJfO  Cases  of  Perineal  Prostatectomy.  465 

the  median  lobe  a  tear  was  made  in  the  urethra  and  the  lobe  was  finally- 
drawn  into  the  left  lateral  cavity  through  the  urethra  and  enucleated 
with  a  portion  of  its  mucous  membrane.  The  tractor  was  then  withdrawn 
and  examination  made  with  the  finger  in  the  urethra.  There  was  no  re- 
maining enlargement,  but  the  sphincter  was  quite  evident,  gripping  the 
finger  somewhat.  After  it  had  been  thoroughly  dilated  the  operator 
thought  that  it  was  not  necessary  to  divide  it  or  excise  more  of  the  median 
portion  of  the  prostate.  The  wound  was  then  closed  with  double  tube 
and  gauze  drainage  as  usual.  The  patient  stood  the  operation  well,  pulse 
at  the  end  being  75.  Infusion  and  continuous  irrigation  on  return  to 
the  ward. 

C07ivaJescence. — The  patient  reacted  well  from  the  operation  and  was 
comfortable  until  the  second  day  when  the  tubes  were  removed.  He  then 
began  to  have  pain  which  came  on  frequently  with  desire  to  urinate. 
Micturition  was  difficult  and  painful.  On  the  sixth  day  after  the  opera- 
tion the  spasmodic  pain  at  intervals  persisting,  a  silver  catheter  was 
passed  and  460  cc.  residual  urine  withdrawn.  For  a  few  hours  the  patient 
was  comfortable,  but  after  that  he  began  to  suffer  frequent  urination  and 
severe  pain,  so  that  it  seemed  evident  that  the  obstruction  had  not  been 
completely  removed.  On  the  eighth  day  after  the  first  operation  the  pa- 
tient was  etherized,  the  wound  broken  open  and  an  examination  made  of 
the  prostatic  orifice.  It  wa?  found  surrounded  by  a  spasmodic  firm  sphinc- 
ter and  in  the  median  portion  a  small  mass  of  mucous  membrane  repre- 
senting the  capsule  of  the  median  lobe  was  present.  With  forceps  and  scis- 
sors this  capsule  and  the  fibrous  median  portion  of  the  sphincter  was  ex- 
cised with  scissors  leaving  quite  a  large  orifice.  Double  drainage  tubes 
were  inserted  as  before,  and  after  excision  of  the  edges  the  wound  was 
closed.  The  patient  stood  the  operation  well  and  convalesced  rapidly.  The 
tubes  were  removed  on  the  day  after  the  operation,  and  the  patient  voided 
without  pain.  On  the  fourth  day  he  had  control  of  urination.  Urine 
passed  through  the  anterior  urethra  on  June  1,  and  the  fistula  closed  com- 
pletely on  June  4,  the  20th  day  after  the  first  operation.  The  patient  was 
discharged  on  June  6,  the  22d  day  after  the  first  operation,  in  excellent 
condition,  able  to  retain  urine  for  seven  hours  at  night  and  four  hours 
during  the  day  and  free  from  pain.  He  had  perfect  control,  the  wound 
was  healed,  urine  was  voided  in  a  large  stream,  was  clear,  and  contained 
no  bacteria,  as  shown  by  stained  centrifugalized  specimen  and  a  silver 
catheter  passed  with  ease  and  found  no  residual  urine. 

Septem'ber  14,  1906. — Letter.  Urine  is  voided  naturally,  about  eight  or 
ten  times  during  the  day  and  none  at  night,  five  or  six  ounces  at  a  time. 
No  pain.  Sexual  intercourse  is  not  entirely  satisfactory  in  that  the  pleas- 
ure is  not  so  great  as  before  operation.  I  have  gained  in  weight  and  am 
entirely  cured. 

Pathological  report. — The  specimen,  G.  U.  295,  consists  of  three  pieces 
of  tissue  representing  the  two  lateral  lobes  and  a  small  pedunculated  me- 
dian lobe,  total  weight  about  8  gm.  The  lateral  lobes  each  weigh  l^o  gm. 
and  the  median  lobe  about  5  gm.     The  tissue  in  the  right  and  median 


466  Hugh  H.  Young. 

lobes  is  lobulated,  soft,  and  on  section  is  succulent  and  composed  of  small 
spheroids.  There  is  a  small  piece  of  mucous  membrane  attached  to  the 
median  lobe.  The  left  lateral  is  distinctly  firmer  than  the  other  two  lobes, 
the  surface  is  not  lobulated,  and  on  section  is  homogeneous  and  contains  no 
spheroids,  it  apparently  contains  a  large  amount  of  stroma.  It  seems  that 
we  have  hypertrophied  tissue  in  the  right  and  median,  while  the  left  lobe 
looks  like  normal  prostatic  tissue,  except  that  it  seems  to  contain  some- 
what more  stroma.  The  pedunculated  median  was  evidently  a  growth 
from  the  subcervical  group  of  glands. 

Microscopic  examination. — ^Sections  from  the  left  lateral  show  a  tissue 
in  which  the  stroma,  excepting  a  few  small  areas,  is  much  in  excess  of  the 
glandular  element.  The  acini  in  many  areas  are  small,  and  about  them 
is  quite  an  extensive  periacinous  sclerosis.  The  inflammatory  infiltration 
often  extends  well  out  into  the  interstitial  tissue,  and  both  the  glandular 
groups  and  the  intervening  stroma  are  infiltrated  with  leucocytes  and 
round  cells  in  quite  extensive  areas.  The  picture  is  that  of  a  chronic  pros- 
tatitis in  which  there  has  been  considerable  fibrous  tissue  formation.  The 
acini  are  not  dilated  and  show  none  of  the  complexity  of  lumina  which 
one  sees  in  hypertrophied  prostates. 

Sections  from  the  right  lateral  show  areas  containing  somewhat  more 
gland  tissue  than  the  left,  but  the  stroma  as  a  whole  is  considerably  in 
excess  of  the  gland  element.  There  has  been  extensive  fibrous  tissue 
hyperplasia,  both  in  the  interstitial  stroma  and  immediately  surrounding 
the  acini.  In  quite  extensive  areas  the  acini  are  small  and  compressed, 
and  many  have  apparently  been  destroyed.  About  many  of  the  acini  fairly 
active  infiammatory  processes  are  still  present. 

Section  from  the  median  lobe. — ^Here  the  stroma  also  predominates,  but 
there  are  a  few  well  defined  gland  accumulations  in  which  the  acini  are 
dilated  and  present  serrated  margins.  In  many  areas  there  is  a  well 
marked  periacinous  sclerosis  with  infiammatory  infiltration,  extending 
well  out  into  the  interstitial  stroma.  The  blood  vessels  show  practically 
no  thickening. 

Case  142. —  Very  large  globular  intravesical  median  enlargevient  of  the 
prostate.  Lateral  lobes  small.  Enucleation  without  difficulty  through 
perineum.  Severe  cystitis  with  exfoliation  of  vesical  mucosa  passed 
through  perineal  wound  on  the  21th  day.     Recent  case. 

S.  No.  19,108.  O.  W.  S.,  age  72,  widowed,  admitted  May  12,  1906. 

Complaint. — f  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  five  years  ago  with  frequency  of  urination 
which  gradually  increased,  but  was  not  associated  with  pain.  About  two 
and  one-half  years  ago  the  patient  began  to  have  dribbling  of  urine  and 
six  months  later  hematuria  and  pain  of  a  dull  aching  character  in  penis 
and  rectum.  He  went  to  a  hospital  in  another  city  where  a  catheter  was 
used  and  prostatectomy  advised.  During  the  past  two  years  his  condition 
has  gradually  grown  worse,  and  he  is  now  voiding  every  half  hour  during 


study  of  lJj-5  Cases  of  Perineal  Prostatectomy.  467 

tlie  day  and  night.  There  is  a  dull  pain  constantly  present  at  the  neck  of 
the  bladder  and  a  very  severe  pain  during  urination.  Hematuria  occurs 
occasionally,  but  he  has  passed  no  stone.  There  is  no  pain  in  back,  hips, 
thighs,  legs,  testicles  or  groins.  He  has  lost  15  pounds  in  weight  and  is 
very  weak.  He  is  able  to  void  only  a  small  quantity  of  urine,  often  only 
a  few  drops  at  a  time  and  has  to  strain  to  start  the  flow. 

Sexual  powers. — ^No  note  made. 

Examination— -The  patient  is  a  thin,  weak-looking,  old  man.  The  mu- 
cous membranes  are  of  fair  color.  There  are  a  few  crackling  rales  at 
the  base  of  the  left  lung.  The  heart  is  enlarged  and  there  is  a  soft  sys- 
tolic murmur  at  the  apex.  The  second  pulmonic  is  loud  and  bell-like. 
The  abdomen  is  negative. 

Genitalia. — Negative.  Double  inguinal  hernise  are  present  for  which  he 
wears  a  truss. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth,  elastic,  about 
the  size  of  a  large  orange.  The  seminal  vesicles  cannot  be  reached  and 
the  rectum  is  negative.    There  are  no  enlarged  glands  present. 

Cystoscopic. — The  patient  is  unable  to  void  (has  been  catheterized  be- 
fore, the  residual  urine  is  usually  large).  The  bladder  capacity  is  large. 
The  cystoscope  shows  a  very  large,  globular  median  lobe  which  fills  the 
base  of  the  bladder.  It  is  impossible  to  see  the  ureters.  The  lateral  lobes 
are  only  slightly  intravesically  enlarged,  and  there  is  no  cleft  between 
them  in  front.  The  mucous  membrane  is  everywhere  normal  in  appear- 
ance with  the  exception  of  a  slight  acute  inflammation.  The  bladder  is 
considerably  trabeculated;  no  stone  or  diverticula  present.  With  finger 
in  rectum  and  cystoscope  in  urethra  it  is  impossible  to  feel  the  beak, 
owing  to  a  very  large  mass  in  region  of  median  portion  of  prostate  and 
trigone. 

Urinalysis. —  (Unfortunately  lost) . 

Preliminary  treatment. — Catheterization  two  or  three  times  daily,  water 
in  abundance,  urotropin. 

Operation,  May  18,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  left  lateral  lobe  was  moderately  enlarged  and  removed  in 
one  piece.  The  right  lateral  lobe  was  considerably  enlarged  and  also  enu- 
cleated in  one  piece.  The  median  lobe  was  very  large  and  could  not  be 
engaged  with  the  double  bladed  tractor.  The  finger  was  then  inserted  into 
the  bladder  and  could  with  difiiculty  be  hooked  around  a  tremendous  pe- 
dunculated intravesical  lobe  which  covered  the  entire  base  of  the  bladder. 
With  the  old  single-bladed  tractor  the  prostate  was  drawn  down  and 
easily  enucleated  mostly  through  the  left  lateral  cavity  (Fig.  57),  a  small 
portion  being  removed  through  the  right  side.  The  urethra  mucosa  was 
torn,  but  none  was  removed,  but  a  portion  of  the  mucous  membrane  cover- 
ing the  summit  of  the  huge  median  lobe  came  away  with  it.  The  wound 
was  closed  as  usual  with  double  tube  drainage,  light  packs  for  the  lateral 
cavities.  The  patient  was  infused  on  the  table,  there  was  more  hemor- 
rhage than  usual,  but  his  condition  at  the  end  of  the  operation  was  good, 
pulse  80.    Continuous  irrigation  on  return  to  the  ward.    Pulse  at  end  100. 


468 


Hugh  H.  Young. 


Convalescence. — -About  one  hour  after  the  operation  the  pulse  became 
quite  weak,  but  it  was  only  120  to  the  minute,  and  in  a  few  minutes  fell 
to  100.  After  that  the  pulse  remained  good.  The  temperature  has  never 
risen  above  99.5°,  and  has  generally  been  normal.  The  tubes  and  gauze 
were  removed  on  the  second  day  after  the  operation,  and  the  patient  was 
out  of  bed  on  the  fourth  day.  On  the  eighth  day  the  wound  became  in- 
fected and  broke  down.     For  a  time  after  that  the  surface  of  the  wound 


Fig.  57. — Large  globular  median  lobe,  moderate  sized  lateral  lobes,  exact 
size. 


was  covered  with  a  dirty  exudate  and  the  wound  was  very  foul.  He  was 
treated  vigorously  by  antiseptic  irrigations  and  applications  of  nitrate  of 
silver  to  the  wound,  and  on  June  6  his  condition  had  improved  consid- 
erably, but  he  was  apathetic  and  complained  of  some  pain  in  the  bladder. 
On  June  14  the  patient  suddenly  began  to  void  urine  through  the  penis, 
and  complained  of  pain  in  the  perineum.  Examination  showed  what 
seemed  to  be  a  slough  in  the  wound.  A  urethral  irrigation  was  given,  and 
following  this  the  patient  had  a  spasmodic  attempt  at  urination,  and  sud- 
denly a  large  mass  was  forced  out  of  the  perineal  wound.     Examination 


study  of  145  Cases  of  Perineal  Prostatectomy.  469 

of  this  showed  that  it  was  a  large,  membrane-like  mass  and  evidently  an 
exfoliated  vesical  mucosa.  Following  this  the  patient  felt  distinctly  more 
comfortable,  but  it  is  remarkable  to  note  that  he  had  not  suffered  greatly. 
The  urine  was  very  purulent,  and  it  is  evident  that  the  bacterial  infection 
of  the  bladder  has  been  very  severe  and  produced  exfoliative  cystitis. 

J.une  15.  1906. — The  condition  of  the  patient  is  good.  The  perineal 
wound  looks  much  healthier,  but  no  urine  as  yet  escapes  through  the 
urethra. 

Septemter  15,  1906. — Letter.  The  perineal  wound  closed  about  five 
weeks  after  the  operation  and  has  remained  healed.  I  void  urine  natu- 
rally at  intervals  of  from  one  to  three  hours.  Suffer  no  pain,  do  not  have 
erections.  My  general  health  is  good  and  I  have  gained  in  weight.  I  con- 
sider myself  cured. 

Pathological  report. — The  specimen,  G.  U.  297,  consists  of  five  pieces, 
weighing  in  all  70  gm.  (Fig.  57).  The  median  portion  was  removed  in 
two  pieces  and  weighs  43  gm.  The  median  lobe  is  formed  of  a  large, 
rounded  mass  which  is  covered  with  mucous  membrane  and  separated  from 
two  lateral  wings  by  deep  clefts.  The  right  lateral  weighs  17  gm.,  and  the 
upper  portion  consists  of  a  large,  smooth  spheroid,  measuring  2  cm.  in 
diameter,  the  remainder  of  the  lobe  is  composed  of  small  spheroids.  The 
lateral  lobe  is  a  lobulated  mass  weighing  10  gm.  All  three  lobes  are  firm 
and  elastic  in  consistency  and  on  section  are  rather  suculent.  They  are 
composed  of  spheroidal  masses,  some  of  which  can  be  enucleated. 

Case  143. — 'Very  slight  hypertrophy  of  median  and  lateral  lobes  of  pros- 
tate.   Diverticulum  of  left  half  of  bladder  containing  ureteral  orifice.    Re- 
cent case. 
■  No.  1261.  G.  W.  B.,  age  53,  married,  admitted  April  10,  1906. 

Complaint. — •"  Prostatic  trouble." 

The  patient  had  gonorrhoea  about  30  years  ago,  complicated  by  swelling 
of  the  testicles  and  later  with  evidence  of  stricture  for  which  he  was 
treated  by  passage  of  sounds.     No  gleet  afterward. 

Present  illness  began  18  months  ago  with  slight  difficulty  and  pain  on 
urination.  There  was  marked  frequency  during  the  day,  but  none  at 
night.  In  November,  1904,  the  symptoms  continuing,  he  consulted  a 
physician  who  told  him  that  he  was  suffering  from  enlarged  prostate  with 
two  or  three  ounces  of  residual  urine,  and  cystitis,  and  he  was  treated  by 
internal  medicines  and  bladder  irrigations  without  a  catheter.  After  two 
months'  treatment,  the  patient  felt  so  much  worse  that  he  discontinued 
treatment.  In  August  he  consulted  a  specialist  in  New  York  who  said 
that  his  prostatic  trouble  was  not  sufficient  for  operation. 

Six  months  ago  his  condition  was  as  follows:  At  times  considerable 
frequency  of  urination  and  slight  difficulty  and  burning  pain  during  mic- 
turition. At  others,  if  particularly  occupied,  three  or  four  hours  might 
intervene  between  urinations.  He  then  consulted  a  physician  who  treated 
him  by  posterior  injections  and  prostatic  massage  with  little  benefit.  The 
patient  has  had  no  treatment  since,  and  his  condition  has  remained  the 


470  Hugh  H.  Young. 

same.  He  has  never  passed  a  calculus,  nor  had  hematuria.  Has  not  had 
pain  in  back,  hips,  thighs,  testicles,  groin  or  rectum.  His  general  health 
has  remained  good,  and  he  has  not  lost  weight. 

Sexual  powers. — 'There  is  a  tendency  to  precocious  ejaculations,  but 
erections  and  intercourse  are  entirely  satisfactory. 

Status  pra'sens.— Micturition  six  times  during  the  day.  Occasional .  at- 
tacks of  considerable  frequency  during  the  day,  but  none  at  night.  The 
stream  is  always  slow,  urination  somewhat  difficult,  and  there  is  always 
a  burning  sensation  in  the  urethra.  No  severe  pain,  no  blood.  General 
health  is  excellent. 

Examination. — ^The  patient  is  a  healthy-looking  man  with  lips  of  good 
color.     No  arteriosclerosis,  pulse  good. 

Genitalia. — No  urethral  discharge.  Right  testicle  smaller  than  the  left. 
Right  epididymis  indurated  and  several  large  nodules  at  upper  end. 

Rectal. — ^Prostate  is  a  little  larger  than  normal,  but  slightly  indurated. 
Moderate  induration  at  the  base  of  each  seminal  vesicle,  but  the  upper 
portions  of  both  vesicles  are  soft.  There  are  adhesions  along  the  outside 
of  the  right  vesicle,  and  the  upper  end  of  the  prostate  of  slight  degree, 
none  along  the  left.  The  prostate  gives  way  on  massage,  the  induration 
being  of  slight  degree. 

The  prostatic  secretion  contains  a  great  number  of  pus  cells,  lecithins, 
epithelial  cells,  large  and  small  granular  cells,  no  spermatozoa. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  65  cc.  residual 
urine;  bladder  capacity  370  cc.  Considerable  washing  is  required  to 
cleanse  the  bladder.  The  cystoscope  shows  a  small,  round  median  bar 
which  is  continuous  with  the  lateral  lobes  without  intervening  sulci.  The 
lateral  lobes  are  very  little  intravesically  enlarged,  and  the  sulci  between 
them  in  front  is  very  shallow.  The  bladder  is  considerably  trabeculated 
and  inflamed.  The  trigone  is  hypertrophied.  The  right  ureter  is  normally 
located,  and  outside  of  it  are  several  prominent  septa  with  several  deep 
pouchs  between.  In  the  region  of  the  left  ureter  is  a  large  orifice  of  a 
diverticulum.  The  ureteral  ridge  is  very  prominent  on  the  inner  side  of 
this  orifice,  but  the  ureteral  orifice  cannot  be  seen,  evidently  having  been 
drawn  into  the  diverticulum.  It  is  impossible  to  introduce  the  cystoscope 
into  the  diverticulum  for  visual  examination  of  its  interior,  but  its  cavity 
was  very  dark,  and  it  is  evidently  of  fairly  large  size.  There  is  no  stone 
present.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is 
easily  felt,  there  is  only  moderate  increase  in  thickness  of  the  median  por- 
tion of  the  prostate. 

Urinalysis. — ^Acid,  small  amount  of  albumin,  no  sugar,  no  casts  seen, 
some  pus,  large  bacilli. 

May  15,  1906.  Operation. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  The  lateral  lobes  were  very  little,  if  at  all,  enlarged,  and  were 
easily  removed  in  one  piece.  In  attempting  to  remove  the  median  portion 
through  the  left  lateral  cavity  a  tear  was  made  in  the  left  lateral  wall  of 
the  urethra.  A  small,  slightly  rounded  lobe  was  then  removed  through 
the  left  lateral  cavity  in  two  pieces.     Examination  with  the  finger  after 


study  of  145  Cases  of.  Perineal  Prostatectomy.  iTl 

removal  of  the  tractor  showed  a  fibrous  condition  still  remaining  beneath 
the  base  of  the  median  lobe  and  this  was  caught  with  forceps  and  excised, 
leaving  a  large  opening  at  the  vesical  neck.  Examination  with  the  finger 
showed  no  remaining  enlargement.  The  wound  was  closed  as  usual  with 
double  tube  drainage,  light  packs  for  the  lateral  cavities.  The  patient 
stood  the  operation  well,  pulse  at  the  end  84.  Infusion  and  continuous 
irrigation  on  return  to  the  ward. 

Convalescence. — The  patient  reacted  well  and  the  highest  temperature 
was  100.6°  on  the  second  day  after  the  operation,  after  that  being  prac- 
tically normal.  The  gauze  was  removed  on  the  day  after  the  operation 
and  the  tubes  on  the  next  day.  The  patient  was  out  of  bed  on  the  third 
day.  The  perineal  fistula  closed  on  the  12th,  and  he  was  discharged  from 
the  hospital  on  the  16th  day  in  excellent-  condition  with  perfect  control 
and  voiding  urine  at  intervals  of  eight  hours  at  night  and  four  hours  dur- 
ing the  day. 

June  11,  1906. — The  condition  of  the  patient  is  excellent.  He  is  free 
from  pain,  the  wound  is  closed,  urine  is  voided  normally  at  long  inter- 
vals.   He  feels  immensely  relieved. 

Septemler  18,  1906. — Letter.  Void  urine  naturally,  four  or  five  times 
during  the  day  and  sometimes  none  at  night,  occasionally  as  much  as  18 
ounces  at  a  time.  No  pain.  Erections  somewhat  imperfect  and  inter- 
course unsatisfactory.  General  health  good.  Urine  contains  no  pus  and 
no  albumin.     Entirely  cured. 

Pathological  report. — T"he  specimen,  G.  U.  294,  consists  of  six  pieces  of 
tissue,  a  right  and  a  left  lateral  lobe,  each  weighing  about  3  gm.,  two  small 
pieces  constituting  the  median  bar  and  weighing  about  half  a  gram,  a 
small  suburethral  piece  of  tissue  which  weighs  half  a  gram,  and  a  pior- 
tion  of  tissue  removed  from  beneath  the  capsule  weighing  1  gm.  The  total 
weight  is  8  gm.  The  tissue  is  firm  and  elastic,  the  surface  is  not  lobulated. 
On  section  it  resembles  somewhat  normal  prostatic  tissue,  except  it  is 
whiter  and  apparently  contains  more  stroma.  In  one  of  the  lateral  lobes 
a  small  nodule  about  the  size  of  a  pin-head,  which  resembles  much  a  be- 
ginning spheroid,  is  seen,  otherwise  the  tissue  is  homogeneous.  The  tissue 
of  the  median  bar  seems  quite  fibrous.  The  suburethral  nodule  seems  to 
contain  gland  tissue  and  resembles  a  small  encapsulated  spheroid. 

Microscopic  examination. — Sections  from  the  lateral  lobes  show  tissue 
in  which  the  glandular  elements  are  far  exceeded  by  the  stroma.  The 
acini  are  for  the  most  part  small,  and  there  has  been  an  extensive  peri- 
acinous  sclerosis,  at  times  in  extensive  areas  nothing  but  vestiges  of  acini 
remain.  Here  and  there  one  encounters  small  areas  where  a  fair  number 
of  somewhat  dilated  acini  are  grouped  together  and  they  are  filled  with 
proliferating  and  desquamated  cells,  but  apparently  no  leucocytes.  The 
stroma  contains  a  large  amount  of  tissue  and  there  is  a  moderate  degree 
of  arteriosclerosis  present.  Quite  numerous  corpora  amylacea  are  seen 
in  the  ducts. 

Sections  from  the  suburethral  tissue  show  it  to  be  more  glandular,  al- 
though the  acini  are  separated  from  each  other  by  rather  broad  bands  of 


472  Hugh  H.  Young. 

stroma  except  in  a  few  small  areas  where  the  culs-de-sac  are  dilated  and 
show  numerous  papillary  projections  and  are  separated  from  each  other 
by  narrow  bands  of  stroma.  A  well-marked  prostatitis  is  present  in  areas 
and  in  these  portions  there  has  been  some  fibrous  tissue  formation. 

A  section  of  tissue  removed  beneath  the  vesical  orifice  is  entirely  com- 
posed of  connective  tissue  and  muscle  bundles.  About  many  of  the  blood 
vessels  there  is  some  round  cell  infiltration  with  a  formation  of  consider- 
able fibrous  tissue. 

Case  144. — Slight  enlargement  of  median  and  lateral  lobes.  Three  vesi- 
cal calculi.     Perineal  prostatectomy  and  lithotomy.     Cured.    Recent  case. 

No.  1229.    J.  D.  Y.,  age  61,  married,  admitted  May  21,  1906. 

Complaint. — "  Frequency  of  urination  and  pain." 

Gonorrhoea  once  as  a  boy,  no  complications  or  sequellse. 

Present  illness  began  one  and  one-half  years  ago  with  a  sudden  attack 
of  great  frequency,  difficulty  and  pain  in  voiding  urine.  He  was  treated 
by  internal  medicines  and  after  two  days  felt  perfectly  well,  but  in  a  short 
time  a  similar  attack  appeared  again,  and  since  then  with  increasing 
frequency.  He  has  not  had  complete  retention  of  urine,  but  last  summer 
was  treated  by  frequent  catheterization  without  benefit.  At  that  time  only 
about  one  ounce  of  residual  urine  was  found.  The  course  of  the  disease 
has  been  characterized  by  gradually  increasing  difficulty  and  frequency  of 
urination,  and  pain  radiating  to  the  end  of  the  penis  and  worse  at  the 
end  of  urination.  There  has  also  been  a  dull  pain  in  the  rectum  and  neck 
of  bladder  when  walking.  He  has  not  had  hematuria  and  there  has  been 
no  loss  of  weight. 

Status  prwsens. — Urination  every  two  hours  during  the  day  and  every 
one  and  one-half  hours  at  night.  Urination  is  free,  but  there  is  pain  at 
the  end  of  urination,  he  also  has  pain  in  walking  and  riding  in  a  car- 
riage, no  pains  elsewhere,  no  hematuria.     General  health  is  fair. 

Sexual  powers. — No  erections  and  no  desire  for  coitus  for  one  and  one- 
half  years. 

Examination. — ^The  patient  is  quite  a  fat  subject,  and  his  color  is  bad, 
but  the  chest  and  abdomen  are  negative  with  the  exception  that  the  lat- 
ter is  large  and  pendulous. 

Rectal.— \T'iie  prostate  is  slightly  enlarged,  symmetrical,  smooth,  firm, 
elastic.     The  seminal  vesicles  are  negative,  no  nodules,  no  glands. 

Cystoscopic. — A  small  coude  catheter  passes  with  ease  and  finds  50  cc. 
residual  urine.  The  bladder  capacity  on  forced  distention  is  210  cc.  The 
cystoscope  shows  three  moderately  large,  irregular,  dark  stones  in  the 
bladder.  The  lateral  lobes  of  the  prostate  are  not  enlarged,  and  there  is 
only  a  slight  median  bar.  Examination  was  not  very  satisfactory  on  ac- 
count of  hemorrhage.  With  finger  in  rectum  and  cystoscope  in  the  ure- 
thra there  is  a  fairly  considerable  increase  in  the  median  portion  of  the 
prostate. 

Urinalysis. — Cloudy,  no  sugar,  albumin  a  trace,  microscopically,  numer- 
ous pus  cells  and  cocci. 


study  of  llfO  Cases  of  Perineal  Prostatectomy.  473 

Operation,  May  22,  1906. — Ether.  Perineal  prostatectomy  by  the  usual 
technique.  Extraction  of  three  calculi  from  the  bladder  through  the  peri- 
neum. The  perineum  was  extremely  fat  and  the  prostate  situated  very 
deep.  It  was  exposed,  however,  with  no  great  difficulty  and  two  slightly 
enlarged  lateral  lobes  removed  each  in  one  piece.  A  small  median  lobe 
about  11/4  cm.  in  diameter  and  a  small  median  bar  were  removed  attached 
to  the  left  lateral  lobe.  Examination  with  the  finger  showed  no  remaining 
enlargement,  and  up  to  this  point  the  urethra  had  not  been  injured.  In 
order  to  make  room  for  the  extraction  of  the  stones  the  urethra  was  then 
divided  along  the  left  lateral  wall  as  far  as  the  vesical  orifice,  the  neck 
of  the  bladder  dilated  with  forceps,  the  stone  forceps  introduced  and  the 
three  calculi  removed  together  at  one  time.  Careful  examination  showed 
no  other  calculi  and  no  fragments.  Examination  of  the  prostatic  orifice 
with  the  finger  showed  no  remaining  enlargement.  The  wound  was  closed 
as  usual  with  double  tube  drainage  for  the  bladder  and  light  packs  for 
the  lateral  cavities.  The  patient  stood  the  operation  well.  Infusion  and 
continuous  irrigation  on  return  to  the  ward.     Pulse  at  the  end  92. 

Convalescence. — The  patient  reacted  well.  The  highest  temperature  was 
102.2°  on  the  third  day  after  the  operation,  but  after  the  fifth  day  was 
normal.  The  tubes  and  gauze  were  removed  on  the  day  after  the  opera- 
tion and  the  patient  was  out  of  bed  on  the  next  day.  On  the  third  day 
urinary  control  was  established,  on  the  fifth  urine  began  to  flow  through 
the  anterior  urethra,  and  on  the  sixth  day  the  fistula  closed  finally.  Dur- 
ing the  second  week  the  patient  suffered  from  vesical  and  urethral  irri- 
tability, but  after  urotropin  was  discontinued  this  disappeared.  The  pa- 
tient was  discharged  on  the  21st  day,  voiding  urine  freely,  in  a  large 
stream,  with  perfect  control,  at  intervals  of  four  hours  and  without  pain. 

June  12,  1906. — ^The  patient  is  in  excellent  condition,  is  entirely  com- 
fortable, and  the  urine  is  only  slightly  cloudy,  but  still  contains  a  few 
cocci.     Is  instructed  to  continue  urotropin. 

September  12,  1906. — Letter.  Urine  is  voided  naturally  about  three 
times  during  the  day  and  three  times  at  night,  six  ounces  at  a  time.  No 
pain,  no  erections.     General  health  good.     Am  cured. 

Pathological  report. — The  specimen,  G.  U.  298,  consists  of  two  pieces  of 
prostate  tissue  weighing  in  all  about  20  gm.  The  right  lobe  weighs  about 
S  gm.  It  is  a  somewhat  oval  mass,  surface  is  lobulated,  consistency  firm, 
but  elastic,  and  on  section  is  fairly  succulent  and  composed  of  numerous 
spheroids.  The  left  lobe  and  median  have  been  removed  in  one  piece  and 
together  weigh  about  12  gm.  The  median  lobe  is  a  pedunculated  lobule, 
rounded,  and  measures  about  1.5  cm.  in  diameter.  The  consistency  of  the 
mass  as  a  whole  is  very  soft,  and  on  section  it  is  made  up  of  lobules  of 
varying  sizes.  No  ejaculatory  ducts.  Three  calculi  have  been  removed, 
the  largest  is  3  cm.  in  diameter  and  1  cm.  thick,  the  other  are  each  2  cm. 
in  diameter  and  1  cm.  thick. 


474  Hugh  H.  Young. 

Case  145. — Slight  median  bar.  Three  previous  operations:  Sicprapubib 
lithotomy,  castration,  Botiini.  Return  of  obstruction,  residual  urine,  and 
frequency.  Perineal  prostatectomy.  Excision  of  median  portion  of  pros- 
tate.   Cured.    Recent  case. 

No.  1169.     J.  K.  T.,  65,  married,  admitted  May  22,  1906. 

Complaint. — *'  Burning  in  the  posterior  urethra;  frequency  of  urination 
and  occasionally  considerable  difficulty." 

No  note  as  to  gonorrhcea. 

Present  illness  began  about  12  years  ago  with  frequency  of  urination. 
He  soon  began  to  suffer  pain  and  a  calculus  was  detected  in  the  bladder 
and  removed  through  the  suprapubic  region.  Later  the  obstruction  to  uri- 
nation grew  worse  and  double  castration  was  performed.  This  was  fol- 
lowed by  slight  improvement,  but  the  patient  continued  to  void  urine 
with  difficulty  and  frequency,  and  he  presented  himself  in  1902,  complain- 
ing of  a  severe  burning  in  the  posterior  urethra  and  urination  two  or 
three  times  at  night.  There  was  also  a  considerable  hesitation  and  in- 
ability to  empty  the  bladder  at  once.  On  examination  the  prostate  was 
smaller  than  normal,  very  firm  but  not  nodular.  The  seminal  vesicles 
and  vasa  deferentia  were  not  palpable.  He  was  given  diuretics  with  no 
benefit. 

Cystoscopic  examination  was  performed.  A  rubber  catheter  met  with 
obstruction  in  the  prostatic  urethra,  but  finally  entered  and  withdrew  135 
cc.  residual  urine.  The  bladder  was  irritable  and  contracted.  The  cysto- 
scope  showed  a  definite  median  bar  which  was  continuous  with  very 
slight  enlargement  of  the  left  lateral  lobe,  there  were  no  sulci  present, 
the  prostatic  margin  being  more  in  the  shape  of  a  constricting  ring.  There 
was  a  definite  pouch  behind  the  median  bar,  the  ureteral  ridges  and  inter- 
ureteral  ridges  were  quite  prominent.  Both  ureteral  orifices  were  seen 
and  secreting  normal  urine.  Back  of  the  left  ureter  was  the  orifice  of  a 
small  diverticulum.  The  bladder  was  considerably  trabeculated  with  num- 
erous pouches.  With  cystoscope  in  urethra  and  finger  in  rectum  the  beak 
was  easily  palpable,  there  was  a  slight  increase  in  the  median  portion  of 
the  prostate. 

April  5,  1902.  Operation. — Local  cocaine  anesthesia.  Bottini  operation, 
three  cuts  with  blade  No.  1,  each  cut  1.7  cm.  in  length,  duration  two  min- 
utes. The  patient  stood  the  operation  well,  there  was  very  little  hemor- 
rhage and  pain.  He  began  to  void  urine  an  hour  later  and  did  not  require 
catheterization.  Two  days  later  he  voided  urine  at  the  intervals  of  two 
hours  without  pain  and  left  the  hospital  in  about  a  week. 

Result. — The  patient  was  wonderfully  improved  by  the  Bottini  opera- 
tion. For  a  long  time  he  was  relieved  of  all  hesitation  and  difficulty  of 
urination,  and  voided  at  much  longer  intervals.  After  two  years  he  began 
to  suffer  with  irritation  in  the  bladder  and  posterior  urethra,  and  a  slight 
hesitation  in  urination;  this  gradually  increased,  and  during  the  past  year 
the  patient  has  been  very  uncomfortable.  He  complains  of  severe  burning 
in  the  posterior  urethra,  hesitation  and  difficulty  in  starting  the  flow  of 
urine,  a  small  stream  and  frequency  of  urination,  particularly  at  night. 


study  of  llf.5  Cases  of  Perineal  Prostatectomy.  475 

If  he  is  busily  occupied  he  is  able  to  retain  urine  for  four  hours  and  can 
then  void  freely,  but  as  a  rule  he  voids  at  intervals  of  two  hours  and  with 
difficulty.     He  has  no  pain  elsewhere  and  no  hematuria. 

Examination. — The  patient  looks  well,  lips  of  good  color. 

Genitalia. — The  testicles  are  absent. 

Rectal. — The  prostate  is  apparently  no  .arger  than  normal,  smooth,  firm, 
no  nodules,  no  tenderness.  The  seminal  vesicles  are  not  distinctly  pal- 
pable and  there  are  no  enlarged  glands. 

Cystoscopic. — .The  patient  voided  210  cc.  A  catheter  was  then  passed 
and  withdrew  50  cc.  residual  urine.  The  bladder  capacity  on  forced  dis- 
tention is  300  cc.  The  cystoscope  enters,  but  is  firmly  grasped  in  the  pos- 
terior urethra.  Study  of  the  prostatic  orifice  shows  a  small  but  definite 
median  lobe  which  lies  to  the  right  of  the  cystoscope.  The  lateral  lobes 
are  somewhat  irregular,  but  only  slightly  enlarged.  The  posterior  and 
left  lateral  Bottini  cuts  are  apparently  visible  as  shallow  depressions.  In 
Series  U,  with  the  beak  looking  upward  and  the  handle  depressed.  No.  1, 
the  median  lobe  is  not  seen.  On  elevating  the  handle  the  median  lobe 
comes  prominently  into  view.  The  bladder  is  much  inflamed,  moderately 
trabeculated.  The  left  ureter  cannot  be  seen.  On  deep  inspiration  a  mod- 
erate amount  of  mucus  is  seen  to  rush  out  of  the  orifice  and  is  then  drawn 
in  on  expiration.  On  the  right  lateral  wall  of  the  bladder  about  2  cm. 
distant  is  the  small  orifice  of  a  second  diverticulum.  There  are  no  other 
diverticula  present  and  no  stone. 

Urine. —  Urine  is  quite  cloudy,  acid,  and  contains  microscopically  pus 
cells  in  moderate  amount.  A  record  of  the  urinations  shows  intervals  of 
one  and  one-half  to  four  hours  during  the  day  and  amounts  from  three  to 
seven  ounces.  During  the  night  he  voided  every  two  hours  in  amounts 
from  two  to  three  and  one-half  ounces,  the  total  quantity  in  24  hours  be- 
ing 48  ounces. 

May  21i,  1906.  Operation.  Perineal  prostatectomy  by  the  usual  tech- 
nique, with  the  exception  that  the  suburethral  method  was  employed,  the 
patient  having  been  castrated.  The  posterior  surface  of  the  prostate  was 
smaller  than  normal,  and  the  lateral  lobes,  when  removed,  were  very  small 
masses  of  tissue  weighing  about  one  gram  apiece.  The  median  portion 
of  the  prostate  was  excised  along  with  the  floor  of  the  urethra.  It  was 
quite  fibrous  and  evidently  producing  obstruction.  Examination  showed 
no  remaining  enlargement.  The  reasons  for  excising  the  floor  of  the  ure- 
thra were:  the  greater  facility  with  which  the  median  bar  could  be  re- 
moved in  this  way,  the  feet  that  the  patient  had  suffered  from  irritation 
in  the  prostatic  urethra  which  we  wished  to  eradicate,  and  because  the 
patient  had  been  castrated  so  that  epididymitis  was  no  longer  feared. 
Examination  of  the  prostatic  orifice  after  the  removal  of  the  median  por- 
tion showed  a  dilated  orifice,  but  no  more  than  has  been  seen  in  many 
cases.  The  wound  was  closed,  as  usual,  with  double  tube  and  gauze  drain- 
age. The  patient  stood  the  operation  well.  Infusion  and  continuous  ir- 
rigation on  return  to  the  ward. 

Convalescence. — The   patient   reacted   well.     The   temperature   arose   to 


476  Hugh  H.  Young. 

101°  after  the  operation,  but  after  the  second  day  was  normal.  The  gauze 
and  tubes  were  removed  on  the  day  after  the  operation,  and  the  patient 
was  out  of  bed  the  next  day.  The  perineal  fistula  healed  finally  on  the 
12th  day,  and  the  patient  was  discharged  on  the  16th  day  after  the  op- 
eration, able  to  retain  urine  for  four  or  five  hours,  voiding  without  pain 
and  in  a  large  stream  and  with  no  incontinence.  Three  days  later  he  re- 
ported that  he  had  slight  incontinence. 

September  20,  1906. — The  incontinence  which  was  present  for  a  while 
after  operation  gradually  diminished  until  August  15th,  since  which  time 
he  has  had  perfect  control.  Urine  is  voided  naturally  about  six  times  in 
24  hours,  four  and  a  half  ounces  being  the  largest  amount.  There  is  no 
pain.  Erections  have  been  absent  for  years.  He  considers  himself  en- 
tirely cured,  but  there  is  evidently  a  slight  contracture  of  the  bladder,  as 
only  220  cc.  of  fluid  can  be  forced  in. 

PatJwIogical  report. — The  specimen,  G.  U.  299,  consists  of  three  pieces 
of  tissue  weighing  in  all  4i/^  gm.  The  right  lobe  is  a  small,  fibrous-looking 
mass  weighing  1%  gm.  No  lobulations.  The  left  lobe  weighs  ^  gm.,  it 
is  firm  in  consistency  and  is  apparently  mostly  fibrous.  The  median  por- 
tion weighs  21/0  gm.,  and  there  is  a  small  piece  of  the  posterior  surface 
of  the  prostatic  urethra  attached,  also  a  slight  piece  of  the  mucous  mem- 
brane of  the  bladder  on  the  upper  surface  of  the  small  rounded  median 
mass.  On  the  posterior  surface  portions  of  the  ejaculatory  ducts  are  in- 
cluded in  the  specimen.  The  tissue  is  firm  in  consistency,  and  on  section 
has  none  of  the  typical  appearance  of  prostatic  hypertrophy.  There  is 
no  spheroidal  tumor  formation,  but  the  tissue  appears  to  be  largely 
fibrous. 


RECTO-UEETHEAL  FISTULA. 

DESCRIPTION    OF    NEW    PROCEDURES    FOR    THEIR    PREVENTION 

AND    CURE. 

By  HUGH   H.  YOUNG,  M.  D. 

There  have  been  seven  cases  of  recto-uretliral  fistnlge  following  op- 
eration in  163  eases  of  perineal  prostatectomy.  These  cases  have  been 
reported  in  detail  in  another  portion  of  this  volume. 

They  are  briefly  as  follows : 

Case  I. — No.  9.  J.  M.  L.,  age  63,  admitted  March  11,  1903.  Perineal 
prostatectomy  March  19,  1903.  No  especial  difficulty  in  separating  rectum 
and  perineum.  Besides  the  packing  in  the  lateral  cavities  a  third  strip 
of  gauze  was  placed  between  the  prostate  and  the  rectum.  The  perineal 
muscles  were  approximated  with  three  buried  catgut  sutures,  but  the  levator 
muscles  were  not  carefully  drawn  together  over  the  rectum.  On  the  night 
following  the  operation  an  assistant  thinking  the  hemorrhage  was  too 
profuse  forcibly  packed  considerable  additional  gauze  in  the  depths  of  the 
wound.  The  packing  was  removed  on  the  sixth  day,  on  the  ninth  day  gas 
escaped  and  on  the  14th  day  feces.  Suprapubic  drainage  (a  suprapubic  fis- 
tula was  present),  was  maintained  for  several  weeks,  and  the  perineal  uri- 
nary fistula  closed.  Later  a  recto-urethral  fistula  formed.  A  second  opera- 
tion was  performed  October  2,  1903.  The  scar  tissue  excised,  the  rectal  and 
urethral  fistulse  closed  separately,  drainage  of  bladder  through  bulbar 
urethrotomy  wound.  The  rectal  wound  broke  down  on  the  seventh  day, 
but  the  urethral  wound  healed.  The  rectal  fistula  closed  finally  on  the  14th 
day,  and  the  bulbous  fistula  on  the  21st  day.  The  patient  has  remained 
well  since. 

Case  II.— No.  24.  O.  S.,  age  62,  admitted  May  2,  1902.  Emaciated  old 
man,  very  weak  condition.  Perineal  prostatectomy  December  19,  1903. 
Levator  muscles  not  drawn  together.  Rectal  fistula  discovered  on  removal 
of  gauze  on  the  third  day. 

January  6,  1904- — Perineal  rectal  fistula  laid  open  by  division  of  anal 
sphincter  and  mucous  membrane,  retained  catheter  in  penis.  Recto- 
urethral  fistula  did  not  heal. 

March  4,  1904- — Repair  of  rectum,  closure  of  urethral  fistula,  drainage 
through  bulbous  urethrotomy  wound.  Both  rectum  and  urethra  broke 
down. 

June  22,  1904- — Closure  of  rectal  fistula,  excision  of  scar  tissue  around 
urethral  fistula,  rubber  tube  drainage  through  urethral  fistula  which  was 
not  closed.     Result,  rectum  broke  down. 


478  Hugh  H.  Young. 

October  6,  1904. — Suprapubic  cystostomy  for  drainage,  closure  of  rectal 
and  urethral  fistulas  separately  through  perineum,  fine  silk  used.  Rectal 
wound  healed  per  primam,  and  did  not  break  down  later. 

Case  III.— No.  26.  R.  K.,  age  61,  admitted  December  30,  1903.  Patient 
in  good  condition.  Perineal  prostatectomy  January  16,  1904.  Levator 
muscles  not  drawn  together.  Following  the  operation  constipation  and 
abdominal  pain,  treated  for  four  days  by  enemata  of  400  cc.  salt  solution 
three  times  a  day,  a  large  rectal  tube  being  used  each  time  (given  without 
knowledge  of  operator  for  some  inexplicable  reason).  Removal  of  gauze 
on  the  fourth  day,  escape  of  feces  through  perineum  on  the  sixth  day. 

January  26  1904. — Rectal  sphincter  stretched  under  ether.  Recto-urethral 
fistula  persisted. 

February  20,  1904. — Separate  closure  of  rectal  and  urethral  fistula  with 
catgut,  drainage  through  bulbous  urethra  with  rubber  catheter.  Result, 
both  rectal  and  urethral  wounds  broke  down.  Both  fistulas  finally  con- 
tracted to  a  pin  point  size. 

May  11\  1906. — Urination  three  or  four  times  a  day  and  twice  at  night, 
about  a  pint  at  a  time.  Perineal  fistula  minute,  only  a  few  drops  of  urine 
escape  through  it.     The  patient  considers  himself  cured. 

Case  IV. — No.  28.  H.  S.,  age  75.  Weak  emaciated  old  man.  Perineal 
prostatectomy  February  1,  1904.  Prostate  small,  hard,  and  adherent  to 
rectum.  Levator  muscles  not  drawn  together.  Gauze  pack  between 
prostate  and  rectum.  Gas  passed  through  the  wound  on  the  day  after  the 
operation  and  fecal  matter  after  removal  of  gauze  on  the  third  day. 

November  10,  1904- — Suprapubic  cystostomy  for  drainage,  separate 
closure  of  rectal  and  urethral  fistulse  through  perineum,  fine  silk  used. 
Both  wounds  rectal  and  urethral  healed  per  primam,  suprapubic  drainage 
for  three  weeks,  after  that  rapid  closure  of  suprapubic  wound,  restoration 
of  normal  urination. 

May  11,  1906. — Urination  normal,  all  wounds  healed. 

Case  V. — No.  34.  J.  K.,  age  65.  Seen  in  Rochester,  New  York,  March 
11,  1904.  Patient  in  good  condition,  sugar  in  urine  in  moderate  amount 
(operator  away  from  home  could  not  wait  for  preliminary  antidiabetic 
diet).  Perineal  prostatectomy  March  11,  1904.  Levator  muscles  not  drawn 
together.  Discovery  of  rectal  fistula  on  fourth  day,  when  the  gauze  was 
removed. 

April  7,  1904- — Urethrotomy  in  bulbous  region,  insertion  of  catheter  for 
drainage. 

Result. — Rectal  and  urethral  fistulge  persist. 

October  18,  1904- — After  preliminary  diabetic  diet  for  two  weeks,  during 
which  the  sugar  fell  from  2%  to  zero,  the  combined  operation  was 
performed.  Suprapubic  cystostomy  for  drainage,  separate  closure  of  rectal 
and  urethral  fistulse  through  perineum.  Slight  breakdown  of  both  rectal 
and  urethral  wounds,  but  complete  closure  after  the  ninth  day.  Suprapubic 
drainage  maintained  for  38  days.    All  wounds  remained  healed. 

May  10,  1906. — Urination  normal,  all  wounds  healed. 


Kecto-Urethral  Fistula?.  479 

Case  VI.  No.  39.  S.  M.  G.,  age  62,  admitted  May  21,  1904.  Patient  in 
good  condition.  Perineal  prostatectomy  May  31,  1904.  Levator  ani 
muscles  not  drawn  together.  Enema  on  the  second  day  followed  by  severe 
pain  in  the  wound.  Removal  of  gauze  on  the  third  day,  escape  of  feces 
through  perineum  on  the  fourth  day. 

July  2,  1904. — Closure  of  rectal  fistula.  Drainage  of  bladder  through 
bulbar  urethrotomy,  the  urethral  fistula  could  not  be  closed.  Breakdown 
of  the  rectal  wound  on  the  seventh  day. 

February  6,  1905. — Closure  of  rectal  fistula,  urethral  fistula  not  closed. 
Drainage  through  catheter  in  penile  urethra.  Rectal  wound  did  not  break 
down.     Final  closure  of  perineal  urinary  fistula. 

May  19,  1906. — Urination  at  intervals  of  four  hours.  Rectal  and  urethral 
fistulas  have  remained  closed.    Condition  excellent. 

Case  VII. — No.  42.  J.  J.  P.,  age  63,  admitted  July  14,  1904.  Patient  in 
good  condition.  Perineal  prostatectomy  July  15,  1904.  Levator  muscles 
drawn  together.     Unsatisfactory  result,  gradual  increasing  residual  urine. 

July  n,  1905. — Second  perineal  prostatectomy.  The  prostate  was  very 
difficult  to  expose  owing  to  considerable  cicatricial  tissue  between  rectum 
and  prostate,  and  a  small  tear  was  made  into  the  rectum  while  endeavor- 
ing to  push  it  back  with  the  finger.  The  opening  was  closed  with  three 
layers  of  silk  sutures.  A  small  median  prostatic  bar  was  then  removed. 
Rectal  wound  broke  down  on  the  22d  day,  but  gradually  diminished  in 
size. 

April  21,  1906. — The  perineal  fistula  is  closed,  but  a  very  small  recto- 
urethral  fistula  persists.  Frequently  no  urine  passes  into  the  rectum, 
but  occasionally  a  small  amount  does.  Urination  normal  at  intervals  of  six 
hours,  no  feces  through  penis.  Combined  operation  advised,  but  patient 
is  so  comfortable  that  he  does  not  wish  anything  done. 

A  review  of  these  cases  brings  out  several  interesting  facts. 

If  we  exclude  Case  I,  in  which  the  rectal  breakdown  was  probably 
due  to  an  unnecessary  stuffing  of  the  wound  with  gauze  several  hours 
after  operation^  and  the  last  case  in  which  an  operative  tear  was  made 
into  the  rectum  while  dissecting  through  scar  tissue  of  a  previous  op- 
eration all  of  the  cases  occurred  within  a  period  of  five  months,  Janu- 
ary to  May,  1904.  During  this  time  the  operator  did  not  draw  the 
levator  ani  muscles  together  with  a  single  suture  of  catgut  as  is  now 
done,  and  in  several  instances  placed  a  third  strip  of  gauze  be- 
tween the  posterior  capsule  of  the  prostate  and  rectum.  In 
two  of  these  cases  enemata  were  given,  (in  one  several  times) 
and  were  followed  by  pain  in  the  wound  and  rectal  break- 
down on  the  fourth  day  in  both  cases.  In  one  case  diabetes  was 
present    and    the    rectum    broke    down    on    the    fourth    day.     In 


480  Hugh  H.  Young. 

the  other  two  cases  the  patients  were  extremely  weak,  emaciated  men 
and  the  rectum  broke  down  on  the  second  and  third  days  respectively. 
In  the  early  operations  the  operator  was  careful  to  draw  the  perineal 
muscles  together  with  catgut  suture  before  closure  of  the  wound,  and 
during  a  period  of  thirteen  months  did  not  have  a  case  of  recto- 
urethral  fistulge  (barring  the  first  case,  as  mentioned  above).  After 
that  the  operator  lost  sight  of  the  advisability  of  drawing  the  levators 
in  front  of  the  rectum,  and  five  fistulse  occurred  in  a  period  of  five 
months.  Since  then  he  has  been  careful  to  approximate  the  levator 
muscles  in  front  of  the  rectum  with  a  single  suture  of  catgut,  and  as 
a  result  there  has  not  been  a  single  case  of  recto-urethral  fistulse  since 
(barring  Case  VII),  a  period  of  two  years.  It  seems  entirely  safe  to 
assume  that  these  recto-urethral  fistulse  resulted  from  break  down  of 
the  rectum  as  a  result  of  absence  of  the  support  and  protection  nor- 
mally afforded  by  the  levator  ani  muscles.  It  is  only  necessary  after 
exposing  the  posterior  surface  of  the  prostate  to  examine  the  anterior 
wall  of  the  rectum  with  a  finger  in  the  rectum  to  demonstrate  how  very 
thin  the  rectal  tissue  is  in  this  location.  The  sphincter  ani  is  lower 
down  and  at  the  point  mentioned  there  is  very  little  muscle  around 
the  rectal  submucosa.  It  is  therefore  only  natural  that  these  cases  in 
which  the  normal  support  was  not  restored,  in  which  sometimes  gauze 
was  packed  against  the  thin  bowel  wall,  or  the  rectum  was  subjected 
to  strain  (if  not  traumatism)  by  enemata  given  with  rectal  tubes, 
should  break  down  after  the  operation.  As  remarked  above  during 
the  past  two  years  there  has  not  been  a  single  case  of  rectal  fistulse 
in  a  consecutive  series  of  118  cases.  During  this  time  the  following 
technique  has  been  followed:  After  completion  of  the  enucleation  of 
the  prostatic  lobes  the  double  catheter  drainage  is  inserted  through 
the  membranous  urethra  into  the  bladder.  A  small  strip  of  gauze  is 
packed  within  each  lateral  cavity  of  the  prostatic  capsule.  A  re- 
tractor is  then  inserted  so  as  to  hold  the  gauze  and  tubes  out  of  the 
way  anteriorly,  the  oiDerator  inserts  a  gloved  finger  into  the  rectum 
and  palpates  the  bowel  wall  between  the  two  fingers.  Should  any  tear 
be  discovered  it  could  be  readily  closed  with  several  layers  of  fine 
silk  sutures.  The  finger  is  then  withdrawn  and  a  single  narrow- 
bladed  retractor  is  placed  in  the  median  line  posteriorly  and  when 
traction  is  made  the  levator  muscles  are  put  on  tension  and  stand  out 
prominently  on  each  side  of  the  wound  as  shown  in  Fig.  1.  A  single 
suture  of  heavy  catgut  is  then  placed  so  as  to  include    the    levator 


Recto-Uretliral  Fistulce. 


481 


muscles  near  the  rectum^  and  when  tightened  draAvs  these  muscles  to- 
gether in  front  of  the  rectum  thus  completely  covering  it,  and  furnish- 
ing support  against  the  straining  at  stool  or  pressure  by  gauze  after  the 
operation. 

Another  important  point  is  the  early  removal  of  gauze  and  tube 
drainage  thus  preventing  a  break  down    of    the    levator  suture  and 


1 


Fig.  1. 


pressure  against  the  rectum.  Following  these  precautions  the  operator 
feels  justified  in  saying  that  recto-urethral  fistuls  ought  rarely  or 
never  to  occur  after  perineal  prostatectomy. 

The  treatment  of  recto-urethral  fistulce. — This  has  for  many  years 
been  a  bete  noire  of  perineal  operations  and  it  is  only  necessary  to  see 
the  number  of  procedures  which  have  been  advised  to  realize  how  in- 
effectual all  efforts  have  been.  Surgeons  have  even  gone  so  far  as  to 
establish  colostomv  in  order  to  do  awav  with  this  distressing  condition. 


482  Hugh  H.  Young. 

The  technique  usuall}^  employed  consists  in  excising  the  cicatrix  sur- 
rounding the  fistulse  and  dosing  the  rectal  and  urethral  openings  sep- 
arately, with  or  without  drainage  of  the  bladder  through  a  retained 
catheter.  In  five  of  the  cases  mentioned  above  this  procedure  was 
adopted  and  the  rectum  broke  down  and  a  fistula  persisted  in  all  but 
one  case,  in  which  it  finally  healed.  In  every  one  of  these  cases  except 
one,  the  urethral  wound  also  broke  down,  and  this  is  the  one  in  which 
the  rectal  fistula  finally  closed  without  further  operation.  It  is  there- 
fore evident  that  the  urethral  fistula  and  the  constant  passage  of  in- 
fected urine  through  the  urethra,  together  with  the  spasmodic  contrac- 
tion of  prostatic,  rectal  and  perineal  structures  which  occurs  during 
urination  are  important  factors  in  the  breakdown  of  the  rectal  sutures. 

After  trying  various  methods  as  detailed  in  the  cases  above  (simple 
dilatation  of  the  rectum,  division  of  anal  sphincter  and  laying  bare  the 
perineal  rectal  fistula,  closure  of  rectal  fistulse  alone,  simultaneous 
closure  of  both  rectal  and  urethral  fistula,  with  drainage  through  a 
catheter  in  penile  urethra,  through  a  bulbous  urethrotomy  or  through 
the  urethral  fistulse  itself),  I  became  convinced  that  it  was  necessary 
to  remove  the  necessity  for  urination  through  the  urethra  or  of  drain- 
age through  the  urethra  in  order  to  prevent  breakdown  of  the  rectal 
wound.  I  therefore  decided  to  supply  suprapubic  drainage  so  that 
all  urine  might  escape  through  the  suprapubic  region  and  the  spas- 
modic efforts  of  urination  be  done  away  with,  followed  by  simultaneous 
closure  of  both  rectal  and  urethral  fistulse  through  the  perineum. 
This  operation  has  been  carried  out  in  three  cases  with  a  perfect 
closure  of  the  rectum  in  each  case,  and  in  these  same  cases  there  was 
always  a  breakdown  of  the  rectal  wound  when  the  suprapubic  drainage 
was  not  provided.  It  therefore  seems  evident  that  the  best  operation 
for  recto-urethral  fistulce  is:  preliminary  suprapubic  cystostomy,  fol- 
lowed by  closure  of  the  rectal  and  urethral  fistulce  through  the 
penneum. 

The  operation  is  best  done  in  the  following  manner :  The  patient  is 
placed  in  the  Trendelenberg  position,  the  bladder  filled  with  fluid 
through  a  silver  catheter.  An  incision  1%  inches  long  is  made  in 
the  skin,  the  recti  muscles  separated,  and  the  anterior  surface  of  the 
bladder  exposed  after  pushing  back  the  perineum.  Two  silk  sutures 
are  inserted  into  the  bladder  wall  not  too  close  to  the  prostato-vesical 
juncture  and  the  bladder  incised,  a  long  drainage  tube  about  the  size 
of  the  little  finger  is  then  inserted  and  the  bladder  closed  tightly 


Becto-Urethral  Fistulce.  483 

around  it  with  catgut.  The  tube  should  not  project  more  than  2  cm, 
into  the  bladder  so  that  its  end  does  not  impinge  against  the  prostatic 
orifice  or  trigone  (the  opening  high  up  on  the  bladder  wall  having 
been  made  so  for  the  same  reason).  A  small  gauze  wick  is  placed 
in  the  prevesical  space  and  the  recti  muscles  and  skin  are  partially- 
approximated  with  interrupted  sutures  of  silver.  The  patient  is  then 
placed  in  the  lithotomy  position,  and  probe  inserted  through  the 
fistulas  into  the  rectum  and  one  also  into  the  bladder  (if  possible). 
A  sound  is  inserted  in  the  urethra.  Incisions  are  then  made  in  the 
perineum  along  the  line  of  the  operative  cicatrix,  the  scar  tissue 
around  the  fistulse  excised  carefully  as  far  as  the  urethra  and  rectum. 
The  edges  of  the  two  fistulse  are  then  excised  until  healthy  tissue  is 
obtained. 

The  rectum  is  closed  first  with  interrupted  sutures  of  fine  silk,  the 
first  layer  through  the  submucosa  and  turning  in  the  mucous  mem- 
brane, but  not  including  it.  The  second  layer  includes  the  musculosa 
and  is  also  of  silk,  the  third  layer  is  of  catgut  and  includes  additional 
musculosa  and  perirectal  muscle  so  as  to  cover  in  the  previous  sutures 
with  a  thick  pad  of  muscle.  Attention  is  then  directed  to  the  urethral 
fistula  which  is  closed  with  one  or  two  layers  of  interrupted  catgut  or 
very  fine  silk  sutures  (the  rectal  wound  is  the  most  important.  There 
is  usually  less  tissue  to  approximate  around  the  urethra).  Before 
closing  the  skin  a  light  pack  of  gauze  is  placed  in  the  rectal  and 
urethral  wounds  and  the  levator  muscles  drawn  well  together  over  the 
rectum  with  two  or  three  sutures  of  catgut.  The  skin  is  partially 
closed  with  interrupted  catgut,  the  gauze  wick  emerging  from  the 
anterior  angle.  Before  leaving  the  table  the  bladder  is  washed  free 
of  blood  by  a  to  and  fro  irrigation  through  the  suprapubic  tube. 
After  return  to  the  bed  the  suprapubic  tube  is  placed  in  a  bottle  on  the 
fioor  with  the  end  immersed  in  water  so  that  siphonage  will  be  se- 
cured (this  does  away  with  the  necessity  of  a  Cathcart  apparatus). 

The  bowels  should  be  kept  quiet  for  at  least  six  days.  If  they  have 
been  thoroughly  emptied  two  days  before  operation,  and  the  patient 
has  been  on  mUk  diet  for  three  days,  little  difficulty  is  experienced  in 
preventing  defalcation  for  a  week.  It  is  best  to  give  a  lead  and  opium 
pill  for  two  or  three  days  and  to  confine  the  patient  to  liquid  diet.  At 
the  end  of  six  days  the  bowels  are  moved  with  as  little  straining  as 
possible.  This  is  best  accomplished  by  injecting  a  small  amount  of  oil 
and  glycerine  into  the  rectum  to  be  retained,  and  giving  the  patient 
Vol.  XIV.— 31. 


484  Hugh  H.  Young. 

an  ounce  of  castor  oil  by  mouth  followed  two  hours  later  by  Eochelle 
salts.  In  this  way  successful  evacuation  of  the  bowels  is  accomplished 
with  little  straining  and  without  the  necessity  of  large  enemata  which 
are  distinctly  objectionable  (not  to  say  dangerous;)  after  all  prostatic 
operations. 

As  remarked  above,  the  procedure  described  by  me  first  in  the 
Journal  of  the  American  Medical  Association,  February  4,  1905,  has 
been  successful  in  every  instance  in  producing  a  closure  of  the  rectum, 
and  I  feel  certain  that  the  suprapubic  drainage  is  an  addition  of  very 
great  value  to  the  plastic  perineal  operation  in  the  successful  treat- 
ment of  these  cases,  and  that  by  its  use  this  horrible  complication  of 
all  perineal  operations  will  be  relieved  of  its  terrors,  and  that  the  ban 
against  attempting  closure  of  recto-urethral  fistulas,  which  has  been 
placed  by  most  surgeons,  will  be  removed. 

As  remarked  above,  however,  recto-urethral  fistulse  should  not  occur 
as  a  result  of  perineal  operations  when  properly  done.  When  the  op- 
eration is  done  through  a  small  median  incision  and  the  prostate  re- 
moved blindly  by  brute  strength  alone,  it  is  impossible  to  see  what  is 
being  done  and  to  avoid  tearing  or  injuring  the  rectum  in  some 
cases,  but  where  the  open  operation  is  performed,  an  inverted  V-in- 
cision  used,  the  central  tendon  and  recto-urethralis  muscle  exposed 
by  blunt  dissection  on  each  side,  and  carefully  divided,  thus  allowing 
the  rectum  to  be  pushed  back  carefully  from  the  prostate,  and  a 
splendid  view  thereby  obtained,  there  is  little  excuse  for  injuring  the 
rectum,  but  if  it  should  be  injured  the  tear  can  easily  be  seen  and 
repaired  (which  is  not  the  case  with  the  blind  operations  done  through 
a  median  perineal  incision). 

By  carefully  drawing  together  the  levator  muscles  in  front  of  the 
rectum  with  a  single  suture  of  catgut  those  cases  of  post-operative  rec- 
tal necrosis  due  to  pressure  of  gauze  or  straining  at  stool  should  be 
absolutely  prevented. 

These  cases  therefore  have  demonstrated  three  things : 

1.  That  a  rectal  break-down  is  usually  due  to  removal  of  the  sup- 
port naturally  afforded  by  the  levator  ani  muscles. 

2.  That  it  can  be  prevented  by  restoring  this  support  by  simply 
approximating  these  muscles  with  a  single  suture  of  catgut. 

3.  That  recto-urethral  fistulse,  once  established,  can  be  easily  cured 
by  supplying  suprapubic  drainage,  when  the  fistulge  are  repaired. 


THE  EAELY  DIAGJ^OSIS  AND  EADICAL  CURE  OE 
CAECmOMA  OF  THE  PEOSTATE.* 

BEING  A  STUDY  OF  40  CASES  AND  PRESENTATION  OP  A  RADICAL 
OPERATION  WHICH  WAS  CARRIED  OUT  IN  FOUR  CASES,  AND 
AN  APPENDIX,  COMPILED  LATER,  CONTAINING  THE  COM- 
PLETE HISTORIES  OF  64  CASES. 

By  HUGH   H.YOUNG,  M.  D. 

The  recent  publications  of  Conrvoisier/  "Wolff/  Socin  and  Burck- 
liardt/  and  Albarran  and  Halle/  have  furnished  a  considerable  stim- 
ulus to  the  study  of  cancer  of  the  prostate,  but  although  the  disease 
has  been  shown  to  be  much  more  frequent  than  formerly  supposed, 
and  the  pathological  aspects  have  been  well  elucidated,  practically 
nothing  has  been  suggested  in  recent  years  as  a  routine  operation  for 
its  radical  cure. 

Albarran's  startling  announcement  that  in  100  specimens  of  sup- 
posed benign  hypertrophy  he  found  more  or  less  pronounced  invasion 
of  carcinoma  in  14,  seems  not  to  have  suggested  the  necessity  of  a 
radical  excision,  and  even  at  this  late  date  we  find  Pousson  ^  and  Haw- 
ley,°  advocating  a  mere  enucleating  prostatectomy,  leaving  behind  the 
prostatic  capsule,  urethra,  anterior  commissure,  the  adjacent  vesical 
mucosa  and  the  seminal  vesicles — structures  which  are  manifestly  in 
intimate  contact  with  the  cancerous  lobes. 

The  importance  of  early  diagnosis  and  radical  methods  of  removal 
has  been  brought  forcibly  to  the  writer's  attention  in  the  past  two 
years  by  the  sad  results  arising  from  his  failure  to  recognize,  and  oper- 
ate radically  in  six  cases  of  early  carcinoma  of  the  prostate — several 
of  which  ought  certainly  to  have  been  cured  by  the  operation  which  he 
has  since  carried  out  in  four  cases. 

The  object  of  this  paper  is  to  give  in  detail : 

I.  The  six  cases  of  early  carcinoma  in  which  the  malignant  nature 
of  the  disease  was  not  recognized  and  a  partial  operation  performed. 

*  Reported  in  brief  in  the  Jolins  Hopkins  Hospital  Bulletin  for  October, 
1905,  in  wbicb  several  inaccuracies  appear,  owing  to  the  inclusion  of  three 
cases  subsequently  shown  not  to  be  primary  carcinoma  of  the  prostate  (see 
second  footnote). 


486  Hugh  H.  Young. 

II.  A  radical  operation,  proposed  as  a  routine  for  cases  of  cancer 
of  the  prostate,  with  histories  of  four  operated  cases. 

III.  A  clinical  and  pathological  study  of  40  cases  of  carcinoma  of 
the  prostate. 

IV.  A  comparison  with  cases  in  the  literature  in  which  operations 
for  carcinoma  of  the  prostate  were  performed. 

V.  Conclusions  as  to  the  practicability  of  early  diagnosis  and  the 
radical  cure  of  the  disease. 

VI.  An  appendix,  containing  detailed  reports  of  64  cases. 

I.  The  Six  Cases  of  Early  Caecinoma  in  which  the  Malignant 

Nature  of  the  Disease  was  not  Eecognized  and  a 

Partial  Operation  Performed. 

Case  I. — Apparently  "benign  prostatic  enlargement.  Bottini  operation. 
Well  for  two  years.  Development  of  carcinoma  of  prostate  and  bladder. 
Death. 

S.  S.,  aged  67  years,  admitted  May  1901.     Of.  No.  141. 

Duration  of  symptoms,  2  years  and  4  months.  Onset  with  slight  fre- 
quency of  urination.  After  4  months  had  retention,  was  given  a  catheter 
which  he  has  continued  to  use  since.  Only  small  amounts  of  urine  can  be 
passed  voluntarily.     No  hematuria.    Very  little  pain. 

General  examination. — Condition  good,  no  emaciation. 

Rectal  examination. — Prostate  much  enlarged,  about  the  size  of  a  small 
orange.  Median  furrow  far  to  the  right,  notch  shallow.  Right  lobe  indu- 
rated and  very  little  enlarged.  Left  lobe  large,  soft,  smooth,  upper  end 
can  just  be  reached. 

Gystoscope  shows  a  very  large  globular  projection  from  the  left  lateral 
lobe  into  the  bladder  with  a  deep  sulcus  above,  slightly  to  the  left  of  the 
median  line.  The  median  portion  has  a  moderately  thick  bar  which 
shows  a  small  sulcus  between  it  and  the  left  intravesical  hypertrophy. 
The  right  lobe  does  not  project  into  the  bladder  at  all. 

Diagnosis. — Prostatic  hypertrophy. 

Bottini  operation. — Four  cuts  made.  For  some  weeks  afterward  patient 
was  fairly  comfortable,  voiding  urine  naturally,  and  did  not  require  cathet- 
erization. 

December,  1901. — Patient  urinates  every  2  to  2%  hours.  Pain  running 
down  to  head  of  penis.  Passes  2  to  3  small  calculi  daily.  Has  lost  no 
weight.  Examination  shows  patient  in  the  same  physical  condition  as 
when  last  seen.  Prostate  is  about  the  same  as  before  operation.  Con- 
tour smooth,  regular,  consistence  soft.  No  induration  around  prostate  or 
in  region  of  the  seminal  vesicle.     Bladder  capacity  about  240  cc. 

Cystoscopic  examination. — Behind  the  prostate  an  irregular,  shaggy, 
fibrous  mass  is  seen.  The  exact  character  of  this  could  not  be  determined. 
Study  of  the  prostatic  orifice  shows  that  the  orifice  of  the  urethra  was 
large;  that  there  was  a  deep,  open  fissure  behind  where  the  posterior  cut 


An  Operation  for  Cancer  of  Prostate.  487 

was  probably  made  through  the  median  bar,  and  on  the  left  side  a  long 
pedunculated  projection  from  the  left  lobe  which  was  freely  movable  in 
the  bladder. 

A  suprapubic  cystostomy  under  cocaine  was  performed  and  the  irregular 
shaggy  mass  seen  with  the  cystoscope  lying  on  the  trigone  was  found  to 
be  a  slough  from  the  Bottini  operation  covered  with  calculous  deposit.  The 
pedunculated  projection  of  the  left  lobe  of  the  prostate  was  excised.  The 
prostatic  orifice  was  found  to  be  covered  with  smooth  mucous  membrane 
and  no  ulceration  was  to  be  felt.  Bladder  negative.  Microscopic  exami- 
nation of  the  pedunculated  lobe  showed  benign  adenoma  of  the  prostate. 

March,  1902. — Patient  voids  urine  naturally  and  without  pain.  Occa- 
sionally passes  a  small  calculus.  Has  a  residual  urine  of  15  cc.  Urine  is 
slightly  cloudy  and  contains  pus  and  bacteria. 

For  the  next  year  and  a  half  the  patient  was  apparently  well.  Urine 
was  voided  easily  and  in  a  large  stream;  he  suffered  no  pain  or  discomfort. 
He  was  seen  again  in  October,  1903.  At  this  time  he  was  beginning  to 
have  pain  in  bladder  and  urethra,  but  he  had  passed  no  blood,  although  a 
few  weeks  previously  he  passed  a  small  stone.  At  times  he  suffers  con- 
siderably on  attempting  to  urinate  and  at  other  times  he  can  void  quite 
freely  and  without  pain.  He  has  not  lost  much  weight.  Catheter  finds 
only  18  cc.  residual  urine  present. 

Cystoscopic  examination. — The  surface  of  the  right  lobe  and  median 
portion  is  smooth.  In  the  region  of  the  left  lateral  lobe  is  a  large  irreg- 
ular villous  outgrowth,  the  surface  is  shaggy  and  very  white  in  character. 
The  cystoscope  has  to  be  passed  quite  a  distance  into  the  bladder  before  it 
clears  the  tumor,  showing  that  the  tumor  lies  on  the  left  half  of  the  tri- 
gone. With  the  cystoscope  in  the  urethra  and  finger  in  the  rectum  a  hard 
ring  of  tissue  is  felt  around  the  instrument  and  both  lobes  seem  indurated. 
Rectal  examination  shows  that  both  lobes  are  enlarged  and  quite  hard, 
and  that  there  is  induration  also  in  the  seminal  vesicles.  No  operation 
was  advised,  but  after  several  weeks  the  pain  and  frequency  of  urination 
were  so  great  that  suprapubic  drainage  was  supplied.  The  patient  grew 
gradually  worse  and  died  early  in  1904. 

Partial  autopsy  was  performed  in  Washington,  D.  C.  Bladder,  prostate, 
and  kidneys  have  been  removed  in  one  piece.  In  separating  the  bladder 
from  the  rectum  the  seminal  vesicles  were  evidently  cut  away  and  left 
with  the  rectum.  The  ureters  and  kidney  pelves  are  considerably  dilated. 
On  section  the  right  kidney  shows  greatly  dilated  calices  and  very  much 
thickened  cortex.  There  is  a  great  deal  of  exudate  lining  the  mucous 
membrane  of  the  calices,  pelvis,  and  ureter.  The  condition  of  the  left 
ureter  is  similar  to  the  right,  but  the  pyo-hydronephrosis  is  not  so  ad- 
vanced. The  kidney  cortex  is  less  abnormal.  The  bladder,  which  has 
been  opened  in  the  median  line  in  front  and  posteriorly  down  to  the  pros- 
tatic urethra,  is  invaded  almost  everywhere  by  a  new  growth  which  pre- 
sents on  the  inner  surface  of  the  bladder.  The  general  aspect  of  the  tumor 
is  that  of  a  rough  cauliflower-like  growth,  necrotic  in  appearance.    The 


488  Hugh  E.  Young. 

prostatic  orifice  shows  a  long  cleft  on  the  left  side  lined  by  mucous  mem- 
brane, evidently  the  site  of  the  Bottini  incision.  The  cut  through  the 
right  lateral  lobe  is  shown  only  by  a  scar  and  the  posterior  cut  is  filled 
up  by  neoplastic  growth.  The  left  lateral  lobe  projects  only  slightly  into 
the  bladder.  The  surface  is  irregularly  rough,  evidently  a  neoplasm. 
The  right  lateral  lobe  projects  about  2  cm.  into  the  bladder.  In  places  it 
is  covered  by  fairly  normal  looking  epithelium,  but  in  others  by  a  neo- 
plasm. On  section  the  prostate  is,  in  the  hardened  specimen,  generally 
white  in  color  with  numerous  small  dots  and  lines  of  a  grayish  color  in  a 
fibrous  looking  stroma.  The  urethra  is  not  involved  except  on  the  floor 
near  the  bladder  orifice.  The  general  appearance  of  the  tumor  on  section 
is,  in  the  hardened  specimen,  much  the  same  as  that  of  the  prostate,  and 
the  two  are  definitely  continuous.  The  seminal  vesicles  are  not  present, 
and  there  is  no  evidence  of  invasion  of  the  growth  in  the  region  above 
the  prostate  nor  back  of  the  bladder.  The  ureteral  orifices  cannot  be 
seen,  but  apparently  open  into  the  bladder  through  the  neoplastic  growth. 
Microscopic  study  of  sections  shows  carcinoma  of  the  prostate  and 
of  the  bladder  involving  the  entire  musculosa.  The  prostatic  carcinoma 
shows  the  stroma  everywhere  invaded  by  alveoli  of  small,  round,  epithelial 
cells.*    The  vesical  carcinoma  shows  numerous  epithelial  nests  or  perles. 

Case  II. — Large  vesical  calculus.  Apparently  benign  enlargement  of 
prostate.  Suprapubic  prostatectomy.  Cure.  Three  years  later  large  retro- 
peritoneal metastases  from  cancer  of  prostate. 

E.  G.  W.  Of.  No.  228.  Aged  67.  Admitted  November  7,  1901.  Suffer- 
ing from  diflaculty  of  urination  of  two  and  a  half  years'  duration.  Catheter 
necessary  for  one  year.  Of  late,  severe  pain  in  bladder,  and  for  six 
months  sciatica  on  the  right  side. 

Examination. — Patient  in  good  condition.  Prostate  considerably  en- 
larged, bulges  into  the  rectum.  Contour  smooth,  regular,  consistence  very 
hard,  some  areas  harder  than  others.  Left  lateral  lobe  larger  than  right. 
Seminal  vesicles  not  indurated.  "  Would  say  prostate  was  quite  scle- 
rotic." 

*  Since  this  was  written  better  sections  of  the  prostate  have  been  ob- 
tained, and  a  careful  study  shows  that  what  was  supposed  to  be  adenocarci- 
noma of  the  prostate  is  in  reality  alveoli  packed  with  epithelial  and  poly- 
nuclear  cells,  a  process  of  inflammation  and  not  carcinoma  at  all.  The 
character  of  the  cancerous  process  seen  in  the  bladder  and  at  the  prostatic 
orifice  is  of  a  squamous  epitheliomatous  type,  and  it  is  evident  that  it  could 
not  have  arisen  from  carcinoma  of  the  prostate  but  it  may  have  come  from 
the  seminal  vesicle.  Since  this  discovery  one  other  case  with  extensive  car- 
cinomatous intravesical  tumors,  and  soft  smooth  enlarged  prostate  which 
had  been  included  in  discussing  the  cases,  has  been  found  to  present  a 
similar  condition.  In  view  of  these  two  cases  a  third  case,  resembling 
the  above  clinically  has  been  excluded  from  the  detailed  report  of  64  cases 
given  later  on. 


An  Operation  for  Cancer  of  Prostate.  489 

Cystoscopic  examination. — Residual  urine  70  cc.  A  large,  rough,  irreg- 
ular calculus  present.  Study  of  the  prostatic  orifice  shows  intravesical 
enlargement  of  both  lateral  lobes  and  median  portion  of  slight  degree. 

Operation,  November  9,  1901. — Suprapubic  prostatectomy  and  lithotomy. 
The  entire  prostate  with  the  prostatic  urethra  was  enucleated  in  one  piece, 
the  capsule  alone  being  left  behind;  this  was  necessitated  by  the  marked 
adhesion  between  the  prostatic  lobes  and  the  urethra.  Patient  made  a 
rapid  recovery  and  since  then  has  had  no  difficulty  in  urination.  On  May 
25,  1905,  he  was  again  seen.  He  then  said  that  urination  became  normal  a 
few  months  after  the  operation  and  had  remained  so  ever  since.  He  can 
hold  urine  for  5  hours,  has  no  difficulty  in  micturition,  no  pain  in  the 
region  of  the  bladder,  prostate,  or  rectum,  no  hematuria.  Five  months 
ago  he  began  to  suffer  pain  beneath  the  costal  margin  on  the  left  side,  of 
a  dull  aching  character  and  never  radiating.  Consulted  surgeons  in  New 
York,  who  made  a  diagnosis  of  tumor  of  the  left  kidney.  Examination 
shows  a  large  palpable  mass  in  the  region  of  the  left  kidney,  movable  on 
respiration,  and  extending  five  fingers'  breadths  below  the  costal  margin. 
The  liver  is  enlarged  and  its  surface  feels  irregular.  Analysis  of  stomach 
contents  shows  absence  of  HCl  and  Oppler-Boas  bacilli. 

Rectal  examination. — In  the  region  of  the  prostate  there  is  a  hard,  ele- 
vated mass  which  extends  upward  and  outward  on  each  side  to  the  pelvic 
wall  to  which  it  is  closely  adherent  as  far  as  the  finger  can  reach.  The 
surface  is  smooth,  but  on  the  left  side  there  is  a  prominent,  large  lobule; 
no  nodules,  however,  are  present.  Several  indurated  cords  are  present  in 
the  region  of  the  seminal  vesicle  on  each  side.  No  enlarged  glands  to  be 
felt,  after  careful  examination  of  the  entire  pelvic  space.  Rectal  mucosa 
soft  and  not  adherent.     Examination  not  painful. 

Cystoscopic  examination. — Catheter  passes  with  ease.  Xo  residual  urine 
present.  Bladder  capacity  375  cc.  Urine  almost  clear,  very  few  pus  cells 
present.  The  cystoscope  shows  a  large  patent  orifice  connecting  the  ure- 
thra with  the  bladder.  The  mucous  membrane  covering  it  is  smooth,  no 
prostatic  enlargements  are  to  be  seen,  no  evidence  of  obstruction.  Bladder 
negative. 

Examination  of  the  specimen  removed  "by  suprapubic  operation. — The 
prostate  has  been  removed  entirely  in  one  piece.  It  is  covered  by  a  smooth 
capsule  and  contains  the  prostatic  urethra.  It  measures  about  4x5x6  cm. 
in  size.  At  the  vesical  orifice  a  small  median  lobe  and  slight  lateral 
enlargements  are  seen.  Transverse  section  of  the  hardened  specimen 
shows  small,  white,  granular  areas  in  a  fibrous  stroma.  Study  of  the 
stained  sections  under  the  microscope  shows  adenocarcinoma,  principally 
in  the  periphery  of  the  gland  near  the  capsule,  which  is  apparently  intact. 
The  carcinoma  varies  in  the  amount  of  gland  element  which  it  contains. 
In  areas  the  acini  are  very  much  in  excess  of  the  stroma  and  in  places 
simulate  very  closely  a  normal  prostatic  hypertrophy  undergoing  active 
proliferation.  The  acini  are  lined  by  tall  cylindrical  epithelial  cells, 
apparently   quite   normal    and   regular   in   appearance.      In    other    areas. 


490  Hugh  H.  Young. 

however,  the  unmistakable  character  of  carcinoma  is  evident.  The  acini 
are  atypical  and  lined  by  an  epithelium  which  has  undergone  involution. 
At  times  the  carcinoma  becomes  iniiltrating  in  character.  Again  solid 
alveoli  of  epithelial  cells  atypical  in  character  and  with  but  slight  tendency 
to  formation  of  acini  are  to  be  seen.  In  the  areolar  tissue  outside  of  the 
prostatic  capsule  small  carcinomatous  areas  are  encountered  which  pre- 
serve an  atypical  adenomatous  form. 

Note. — This  case  has  been  entirely  cured  of  all  urinary  obstruction  by 
suprapubic  prostatectomy  three  and  a  half  years  ago.  He  suffers  only 
from  symptoms  in  the  region  of  the  left  kidney  and  stomach.  The  mark- 
edly indurated  mass  in  the  region  of  the  prostate  at  once  suggests  car- 
cinoma, and  the  section,  which  had  not  previously  been  studied,  confirms 
this.  The  diagnosis  of  metastases  to  retro-peritoneal  glands,  stomach,  and 
liver  is  therefore  made  and  an  operation  is  not  advised. 

The  patient  died  during  the  fall  of  1905.    No  autopsy. 

Case  III. — Diagnosis:  Small  sclerotic  prostate.  Bottini  operation. 
Death  one  year  later.    No  autopsy. 

W.  H.,  aged  56  years,  admitted  May,  1902.     Of.  No.  206. 

Duration  of  symptoms,  two  years.  Onset  with  frequency  of  urination. 
This  gradually  increased  until,  when  seen,  he  was  voiding  20  to  30  times 
in  24  hours.  Considerable  straining,  some  hesitation.  Never  passed  any 
blood,  never  any  pain  on  urination,  but  has  a  rather  severe  pain  in  the 
region  of  the  sacrum.     Thinks  he  has  lost  considerable  weight. 

Examination. — Strong-looking,  well-nourished  man.  Residual  urine  400 
cc.    Has  never  had  complete  retention. 

Rectal  examination. — Prostate  is  enlarged  in  a  very  peculiar  manner. 
The  right  lobe  is  symmetrically  enlarged,  very  hard  in  consistence,  and 
might  be  called  a  moderate  hypertrophy  of  the  sclerotic  type.  The  left 
lobe  is  almost  twice  as  long,  the  upper  end  extending  up  far  beyond  the 
upper  limit  of  the  right,  and  directed  somewhat  outward  along  the  course 
of  the  seminal  vesicle.  This  lobe  is  also  broader  than  the  right  and 
projects  more  toward  the  rectum.  Contour  smooth,  but  the  consistence 
is  also  extremely  hard.  The  median  furrow  is  obliterated  between  the  two 
lobes  and  there  is  no  notch. 

Cystoseopic  examination  showed  a  median  bar  of  moderate  degree,  with 
a  round  lobule  upon  each  side  just  before  it  joined  the  lateral  lobe.  The 
lateral  lobes  projected  very  little  into  the  bladder,  in  fact  the  contour  of 
the  urethra  was  about  normal.  With  the  finger  in  the  rectum  and  cysto- 
scope  in  the  urethra  the  prostate  was  found  to  form  a  very  hard,  thick 
ring  around  the  shaft  of  the  instrument.  The  beak  of  the  instrument 
could  not  be  felt  in  the  bladder  beyond.  A  note  made  at  the  time  states, 
"  this  prostate  is  the  hardest  I  have  ever  felt,  being  of  stony  consistence. 
Prostatectomy  would  be  practically  impossible  to  perform  on  account  of 
induration." 

A  Bottini  operation  was  done  under  ether,  and  he  was  very  much  re- 
lieved.    On  discharge  he  could  hold  his  water  about  two  hours.    No  pain. 


An  Operation  for  Cancer  of  Prostate.  491 

Urine  passed  with  ease.  Residual  from  75  cc.  to  110  cc.  He  feels  very- 
much  improved. 

He  returned  again  in  September,  complaining  of  rheumatism.  Has  no 
trouble  in  voiding  urine  and  voids  about  twice  during  the  day,  but  for 
the  past  five  weeks  has  suffered  pain  at  the  end  of  his  spine  and  down 
both  legs.  He  says  that  pain  has  been  so  considerable  that  he  has  had  to 
use  morphia.  (Unfortunately  no  note  made  of  examination.)  He  died 
one  year  later.    No  autopsy. 

Note. — In  the  light  of  recent  cases,  it  seems  remarkable  that  I  should 
not  have  recognized  this  case  at  once  as  one  of  carcinoma  of  the  prostate. 

Case  IV. — Bottini  operation  for  supposed  'benign  enlargement  of  pros- 
tate.   Later  diagnosis,  carcinoma.    Alive  five  years  after  onset. 

J.  S.,  aged  68  years,  admitted  August  1902.     Of.  No.  800. 

Duration  of  symptoms,  two  years.  Onset  sudden  with  increased  fre- 
quency of  urination  about  every  half  hour  during  the  day  and  several 
times  at  night.  Considerable  precipitancy  and  pain  if  desire  is  not 
satisfied.  This  first  severe  attack  gradually  wore  off,  but  urinary  difficulty 
gradually  increased.  Since  then  he  has  had  periods  of  varying  discomfort. 
Never  much  pain,  but  if  present  it  was  in  the  bladder  region.  Has  not  lost 
any  weight.    Weighs  202  pounds.    No  history  as  to  hematuria. 

Status  prwsens. — On  entering  the  hospital  he  had  retention  for  the  first 
time,  about  450  cc.  urine  being  drawn  off.  Was  then  catheterized  for 
several  weeks,  and  at  one  time  as  much  as  1200  cc.  removed. 

Rectal  examination. — Prostate  is  peculiar,  is  enlarged,  especially  in  the 
lateral  diameter,  and  the  left  lobe  is  more  affected  than  the  right.  The 
finger  cannot  quite  get  beyond  it.  The  groove  is  distinct,  but  near 
the  apex  on  the  left  side  an  indurated  mass  of  stony  hardness,  the  size 
of  a  hazel-nut,  can  be  felt.  On  the  right  side  a  similar  but  smaller  and 
less  indurated  mass  can  be  made  out.  In  parts  the  prostate  is  soft  and 
pultaceous. 

A  Bottini  operation  was  performed  and  an  immediate  good  result  ob- 
tained. A  short  time  after  he  had  to  get  up  only  once  at  night  to  urinate 
and  during  the  day  voided  every  three  or  four  hours,  but  at  times  there 
was  considerable  blood  in  urine.  He  continued  to  pass  his  water  fairly 
freely  until  May,  1904,  when  he  began  to  use  a  catheter. 

In  December,  190-!/,  the  patient  was  using  his  catheter  four  times  a  day 
and  the  same  number  of  times  at  night  and  unable  to  void  any  urine 
voluntarily.  "  Has  no  pain  at  any  time  except  some  bladder  pain  after 
holding  water  for  several  hours.  Weighs  about  168  pounds  and  says  he 
has  gained  about  8  pounds  in  the  last  few  months." 

Examination,  December,  1904- — He  has  general  glandular  enlargement. 
The  glands  in  the  posterior  and  anterior  triangles  of  the  neck  as  well  as 
the  supraclavicular  glands  are  enlarged,  but  not  especially  hard;  are 
freely  movable.  Some  of  the  glands  are  1%  cm.  in  diameter.  Epitroch- 
lears  are  not  enlarged.  Glands  of  groin  enlarged,  but  freely  movable, 
and  not  particularly  hard.  No  evidence  of  spinal  cord  involvement  or 
nerve  pressure. 


493  Hugli  H.  Young. 

Rectal  examination. — Prostate  much  enlarged,  irregular,  of  stony  hard- 
ness in  places;  the  upper  outlines  cannot  be  reached.  The  left  lobe  is 
larger  than  the  right,  its  surface  is  more  irregular,  containing  one  large 
nodule.  The  induration  extends  upward  and  outward,  particularly  on  the 
left,  the  upper  limit  being  imposible  to  reach.  It  is  apparently  closely 
adherent  to  the  lateral  bony  structure  of  the  pelvis  as  it  extends  upward 
and  outward.  The  prostate  itself  does  not  seem  to  be  adherent  to  the 
pelvic  structures.  In  the  median  line  above  the  prostate  is  an  induration 
between  the  seminal  vesicles.  The  upper  end  of  this  can,  however,  be 
passed.  Between  the  rectum  and  the  prostate  in  the  middle  line  are  two 
small  shot-like  bodies. 

Cystoscopic  examination  shows  three  stones.  On  each  side  of  the  bladder 
to  the  outside  of  the  probable  location  of  the  ureteral  orifice  was  an  ele- 
vated mass  probably  a  tumor.  That  on  the  left  side  was  quite  large,  and 
at  its  summit  was  covered  with  an  irregular,  white,  shaggy  mass.  The 
prostatic  orifice  shows  two  lateral  lobes,  the  left  being  the  largest.  Be- 
tween them  there  is  a  deep  cleft  in  front  and  behind.  With  the  finger 
in  the  rectum  and  cystoscope  in  the  urethra  the  beak  cannot  be  felt  but 
there  is  apparently  no  increase  in  the  median  portion  of  the  prostate. 

In  February,  1905,  he  was  catheterizing  himself  every  two  to  three 
hours;  suffers  no  pain  in  legs  or  thigh,  or  bladder,  but  at  times  has  a 
severe  pain  in  the  rectum,  the  left  side,  and  the  back;  has  lost  10  pounds 
in  the  last  three  months.  The  stones  were  removed  by  litholapaxy.  After 
that  he  was  much  more  comfortable.  Could  hold  urine  longer  than  before 
and  did  not  have  to  catheterize  himself  for  six  hours. 

May  12,  1906. — Patient  returns  for  examination.  He  says  he  is  perfectly 
comfortable,  suffers  no  pain  in  the  bladder,  urethra,  perineum,  rectum, 
back,  hips,  legs,  groins,  or  testicles.  He  has  gained  20  pounds  since  the 
last  operation,  and  enjoys  excellent  health.  He  voids  urine  at  intervals 
of  from  two  to  four  hours.  He  catheterizes  himself  at  bed  time  and 
removes  125  cc.  residual  urine.  He  does  this  because  he  is  able  to  sleep 
longer  and  because  he  finds  that  a  large  soft  rubber  catheter  keeps  his 
urethra  open,  there  being  a  tendency  to  stricture.  Catheterization  is  ac- 
complished easily  without  pain  or  hemorrhage.  Passed  no  blood,  no  calculi 
since  the  last  operation. 

Examination. — The  patient  looks  well,  lips  of  good  color.  The  anterior 
and  posterior  cervical,  epitrochlear  and  the  inguinal  glands  on  both 
sides  are  enlarged. 

Rectal. — There  is  considerable  enlargement  particularly  on  the  left  side 
where  the  consistence  is  very  firm,  presenting  a  very  hard  sharp  edge. 
The  surface  is  irregular,  nodulated,  extremely  hard  and  in  the  region  of 
both  seminal  vesicles,  and  between  them  is  an  indurated  mass  continuous 
with  the  prostate  the  upper  end  of  which  cannot  be  reached.  On  the 
left  side  the  involvement  of  the  structures  above  the  vesicle  is  most  marked 
and  there  is  a  large  mass  of  glands.  On  the  right  side  there  is  considerable 
involvement,  but  no  glands  are  felt.     The  sacral  glands  are  not  palpable. 


An  Operation  for  Cancer  of  Prostate.  493 

The  rectal  mucosa  is  soft  and  not  adherent,  but  there  are  a  few  shot  like 
bodies  apparently  in  the  muscle  of  the  rectum. 

The  urine  is  slightly  cloudy  and  about  150  cc.  is  passed  at  one  time. 
Sp.  Gr.  1019,  markedly  acid,  small  amount  of  albumin,  no  sugar,  no 
casts  seen,  much  pus,  many  bacilli. 

Case  V. — "  Small  sclerotic  prostate."  Bottini  operation.  Two  years 
later.     Carcinoma.    Death.    No  autopsy. 

A.  F.,  aged  60  years,  admitted  September,  1902.     Of.  No.  324. 

Duration  of  symptoms,  three  years.  Onset  with  increased  frequency  of 
urination  but  very  little  difficulty.  Got  up  two  or  three  times  at  night 
and  voided  every  two  to  two  and  a  half  hours  during  the  day.  This  con- 
tinued until  July,  1901,  when  he  had  an  attack  of  acute  retention — about 
1500  cc.  of  urine  being  drawn  off.  He  got  along  very  well  without  the 
catheter,  although  the  frequency  of  urination  gradually  increased  until  he 
was  voiding  about  every  two  hours  night  and  day.  In  July,  1902,  he  had 
another  complete  retention;  after  this  he  voided  naturally,  but  with  in- 
creased frequency  until  about  10  days  ago,  when  he  had  another  attack 
of  retention. 

Status  prwsens. — Voids  urine  about  five  times  at  night  and  about  every 
one  and  a  half  to  two  hours  during  the  day.  Slight  pain  is  present  when 
bladder  is  full,  otherwise  none. 

Rectal  examination. — Prostate  enlarged,  median  furrow  shallow,  notch 
shallow,  hard  to  reach  beyond  it.  Left  lateral  lobe  larger  than  right,  more 
bulging,  extends  further  upward  and  outward  where  it  is  continuous  with 
seminal  vesicle.  Both  are  indurated.  Left  lobe  has  a  very  hard  surface 
and  somewhat  nodular.  Right  lobe  is  softer  but  also  indurated.  Urine 
clear.     Acid,  no  albumin,  no  sugar.     Sp.  gr.  1021. 

Cystoscopic  examination. — There  is  a  definite  but  not  very  great  hyper- 
trophy of  the  median  and  two  lateral  lobes  in  the  shape  of  a  collar  with 
one  sulcus  in  front  between  the  two  lateral  lobes.  The  right  lobe  projects 
a  little  more  into  the  bladder  than  the  left.  The  median  bar  is  moderately 
thick  and  elevated  above  the  trigone.  A  note  made  at  the  time  says,  "  we 
have  to  deal  with  a  hypertrophy  of  moderate  degree  and  probably  of 
inflammatory  and  sclerotic  type." 

A  Bottini  was  performed  and  the  immediate  result  was  very  good.  He 
could  hold  water  five  to  6  hours  during  the  night  and  a  reasonable  length 
of  time  during  the  day.  He  remained  very  well  until  January,  1904,  when 
he  began  to  have  difficulty  and  increased  frequency  of  urination  and  con- 
siderable pain,  and  noticed  a  few  months  later  some  blood  in  urine.  In 
April,  1904,  was  voiding  urine  with  considerable  difficulty,  every  20  to  25 
minutes,  "  suffers  pain  in  the  penis,  particularly  after  urination.  Has 
lost  10  pounds  and  has  suffered  a  great  deal.  Complexion  sallow;  patient 
looks  badly." 

Rectal  examination. — Prostate  very  large,  transversely  twice  as  broad  as 
normal,  irregular  in  contour,  nodular,  closely  adherent  to  the  rectum,  and 
exceedingly  hard.     Upper  end  confluent  with  nodular,  greatly  indurated, 


49-i  Hugli  H.  Young. 

seminal  vesicle  on  both  sides.  Catheter  shows  from  175  cc.  to  400  cc. 
residual  urine. 

Cystoscopy. — Examination  of  the  prostatic  orifice  shows  a  cleft  in  front 
and  one  low  down  to  the  right.  The  right  lateral  lobe  is  in  the  shape  of 
a  rounded  intravesical  projection.  The  left  lateral  lobe  is  also  consider- 
ably enlarged.  The  surface  of  the  median  bar  and  lateral  lobe  is  irregular. 
With  the  finger  in  the  rectum  and  cystoscope  in  the  urethra  it  is  impos- 
sible to  feel  the  beak,  owing  to  an  indurated  mass  in  the  median  portion. 
The  cystoscopic  examination  shows  only  one  Bottini  cut. 

Urine  contains  numerous  pus  cells,  no  organisms.  He  was  treated  by 
urethral  dilation  and  this  improved  his  ability  to  void.  In  October,  1904, 
a  suprapubic  operation  had  to  be  done  on  account  of  difficulty  of  cathe- 
terization and  pain  in  bladder  and  urethra,  and  he  gradually  weakened 
and  died  December,  1904. 

Case  VI. — Mistakenly  diagnosed  "  benign  hypertrophy."  Operation,  peri- 
neal prostatectomy — enucleation  of  lodes.  Recurrence.  Death  one  year 
later. 

J.  J.  S.,  aged  75,  admitted  September  18,  1903.  J.  H.  H.  Nos.  15,199  and 
16,392.     Of.  No.  420. 

Duration  of  symptoms,  three  years.  Onset  with  increased  frequency  of 
urination  and  slowness  of  stream,  urination  gradually  becoming  more  fre- 
quent and  difficult.  Finally  a  complete  retention  of  urine,  after  which  he 
had  to  be  regularly  catheterized  (18  months).  No  hematuria.  Consid- 
erable pain,  spasmodic  in  character  when  bladder  becomes  full.  This  has 
been  present  since  catheter  life  began.  Pain  generally  situated  in  the 
perineum,  but  occasionally  radiates  to  the  end  of  the  penis  and  is  quite 
severe.     No  systemic  symptoms. 

Status  prGEsens. — Unable  to  void  urine  voluntarily.  Catheter  used  every 
four  to  five  hours.  General  health  fair.  Frequent  spasmodic  pains  in 
perineum. 

Examination. — No  glandular  enlargement.  Abdomen  and  chest  practi- 
cally negative. 

Rectal  examination. — Prostate  considerably  enlarged  and  presses  con- 
siderably towards  the  rectum.  Shape  of  prostate  symmetrical.  Long 
diameter  transverse,  size  is  that  of  a  small  apple.  Median  furrow  oblit- 
erated, notch  shallow,  contour  slightly  irregular  and  nodular,  consistence 
rather  hard,  not  tender.  Seminal  vesicles  not  palpable.  Prostate  seems 
closely  adherent  to  the  bony  pelvis. 

Cystoscopic  examination. — Study  of  the  prostatic  orifice  shows  that  the 
right  lateral  lobe  projects  farther  into  the  bladder  than  the  left,  which  is 
rather  small.  In  the  median  portion  there  is  a  small  but  definite  median 
bar.  The  surface  of  the  prostate  is  smooth,  no  ulcerations  seen.  Bladder 
greatly  trabeculated  and  inflamed,  capacity  240  cc,  tonicity  good.  No  cal- 
culus seen.  Urine  is  very  foul.  Sp.  gr.  1017.  Reaction  slightly  alkaline, 
no  sugar.  Cloud  of  albumin.  Very  large  numbers  of  organisms,  both 
cocci  and  bacilli.     The  diagnosis  of  prostatic  hypertrophy  was  made  and 


An  Operation  for  Cancer  of  Prostate.  495 

the  usual  perineal  enucleation  of  the  lateral  lobes  and  median  bar  per- 
formed. The  lobes  were  rather  hard  and  adherent  and  considerable  diffi- 
culty was  experienced  in  enucleation.  The  median  portion  of  the  prostate 
was  found  to  be  intimately  incorporated  with  the  vasa  deferentia,  and 
these  were  unintentionally  excised  with  part  of  the  median  bar.  Patient 
did  very  well  after  the  operation.  Two  months  after  he  could  hold  his 
urine  from  five  to  seven  hours  in  the  day  and  voided  every  three  hours  at 
night.  The  fistula  had  entirely  healed.  Ten  months  after  the  operation 
the  fistula  was  again  leaking;  the  stream  of  urine  slow  in  starting;  no 
pain  present,  but  quite  a  severe  burning  sensation  along  the  urethra. 
Has  lost  25  pounds  in  weight.    500  cc.  residual  urine  found. 

On  rectal  examination  a  mass  of  considerable  dimensions  was  felt  in 
the  region  of  the  prostate,  bulging  into  the  rectum.  The  seminal  vesicles 
could  not  be  felt,  but  in  that  region  was  a  mass  continuous  with  the  pros- 
tate. In  the  middle  line  the  upper  limits  of  the  prostate  could  be  passed 
and  nothing  abnormal  felt.  General  contour  irregular,  consistence  firm 
but  nowhere  of  very  great  hardness.  The  rectal  mucosa  was  not  adherent 
and  no  enlarged  glands  were  felt.  On  cystoscopic  examination  there  was 
a  medium  sized  enlargement  of  the  median  portion,  and  fairly  considerable 
enlargement  of  both  lateral  lobes  shown.  No  ulcerations  present.  Behind 
the  median  bar  an  irregular,  ragged  mass  was  seen,  which  was  probably 
either  tumor  or  a  blood  clot  disintegrating.  A  Bottini  operation  was  per- 
formed. Patient  left  the  hospital  slightly  improved,  but  gradually  became 
weaker  and  died  several  weeks  later. 

Microscopic  study  of  the  tissue  removed  from  the  median  portion  of  the 
prostate  including  the  vasa  deferentia  shows  adenocarcinoma. 

The  carcinoma  is  a  very  cellular  one,  and  is  of  the  adenoma  type,  at  times 
becoming  infiltrating.  The  acini  at  times  are  very  small  and  so  closely 
set  that  an  intervening  stroma  is  made  out  with  difficulty.  At  other  times 
the  acini  are  separated  by  considerable  bands  of  stroma.  At  numerous 
points  lines  of  epithelium  infiltrating  between  the  stroma  bundles  are  seen, 
and  is  often  of  such  a  character  as  to  almost  suggest  round  celled  infiltra- 
tion. The  epithelium  lining  the  acini  is  rather  of  a  cylindrical  type, 
but  it  varies  a  great  deal  in  shape.  This  is  an  adenocarcinoma  without 
any  solid  tubules,  but  with  occasional  areas  of  a  scirrhus  type. 

Eemaeks. — The  foregoing  six  cases  in  which  the  writer  failed  to 
recognize  the  prostatic  enlargement  as  malignant  are  worthy  of  careful 
attention.  In  none  of  them  were  the  classical  symptoms  of  prostatic 
carcinoma  as  nsually  given  present.  In  no  case  had  there  been  hemat- 
uria and  in  only  two  cases  was  pain  present  and  in  one  of  these  a  large 
vesical  calculus  was  found.  Only  one  of  the  patients  had  lost  weight. 
None  presented  the  features  of  Guyon's  "  Carcinose  Prostato-Pelvienne 
diffuse,"  and  the  seminal  vesicles  were  indurated  in  only  two  cases. 
The  clinical  picture  of  nearly  all  of  the  cases  was  that  of  sclerotic 


496  Hugh  H.  Young. 

prostatic  enlargement,  which  has  been  so  frequently  described,  and  this 
was  the  diagnosis  made.  In  four  of  the  cases  both  lobes  were  indura- 
ted, in  the  fifth  only  one  lobe  and  in  the  sixth  there  was  a  hard  nodule 
at  the  upper  end  of  each  lateral  lobe.  The  cystoscope  showed  very  little 
outgrowth  of  the  lateral  or  median  portions  of  the  prostate  into  the 
bladder  with  the  exception  of  one  ease  (and  here  this  lobe  proved  to 
be  adenoma).  Marked  induration  and  absence  of  intravesical  out- 
growths were  therefore  the  two  signs  common  to  all  of  the  cases,  and 
these  may  now  be  taken  as  very  suggestive  of  carcinomatous  enlarge- 
ment. 

The  results  of  palliative  operation  in  these  cases  (suprapubic  pros- 
tatectomy once,  perineal  prostatectomy  once,  Bottini  operation  four 
times)  showed  that  only  by  means  of  much  more  radical  measures  and 
early  diagnosis  could  there  be  a  hope  of  cure  in  such  cases. 

II.  A  Eadical  Operation"  Peoposed  as  a  Eoutine  eor  Cases  of 

caeciisroma  of  the  prostate  v7ith  histories  oe  4 

Operated  Cases. 

In  March,  1904,  a  gentleman  aged  70  years  who  had  been  com- 
plaining of  urinary  trouble  for  only  one  year,  for  which  a  Bottini 
operation  had  been  performed  in  Philadelphia,  with  only  temporary 
benefit,  presented  himself.  He  suffered  a  slight  pain  in  the  penis  and 
bladder  and  perineum  on  urination. 

On  examination  by  rectum,  a  hard  slightly  nodular  prostate,  with  a 
prolongation  of  the  induration  into  the  region  of  the  left  seminal 
vesicle,  was  felt.  The  cystoscope  showed  only  a  little  median  and  no 
lateral  prostatic  enlargement,  not  sufficient  to  account  for  the  large 
residual  urine  present.  There  had  been  no  hematuria,  no  loss  of 
weight,  the  prostate  was  not  tender,  and  no  enlarged  glands  were  to  be 
felt,  but  the  diagnosis  of  carcinoma  seemed  justified,  and  a  radical 
operation  was  advised. 

The  operation  proposed  was  as  follows :  To  expose  the  prostate  and 
insert  the  tractor  as  in  my  ordinary  prostatectomy  operation,  to  free 
the  posterior  surface  of  the  prostate,  and  if  the  examination  confirmed 
the  diagnosis,  to  cut  the  prostate  loose  from  the  membranous  urethra, 
to  divide,  the  pubo-prostatic  ligaments,  separate  the  prostate  from  the 
bladder  at  a  safe  distance  from  the  prostate,  incising  the  trigone  in 
front  of  the  ureters,  and  after  dividing  the  vasa  deferentia  as  high  up 


An  Operation  for  Cancer  of  Prostate.  497 

as  possible,  to  remove  the  prostate,  vesical  cuff  and  seminal  vesicles  in 
one  piece.  The  operator  also  proposed  to  restore  the  defect  by  anas- 
tomosing the  anterior  wall  of  the  bladder  to  the  membranous  urethra 
if  that  were  possible.  The  patient  readily  acquiesced,  and  with  the 
kind  assistance  of  Dr.  Halsted  the  operation  was  successfully  carried 
out,  exactly  as  planned,  April  7,  1904.  Ko  great  difficulty  was  ex- 
perienced in  excising  the  entire  prostate  and  seminal  vesicles  intact 
with  the  vasa  deferentia  and  vesical  neck,  the  enucleation  and  dis- 
section apparently  giving  the  involved  structures  a  wide  berth. 

The  patient  reacted  well,  the  convalescence  was  good,  the  perineal 
wound  closed  tight,  and  free  urination  through  the  urethra  was  soon 
established — in  fact  the  operation  was  so  satisfactory  that  it  seemed 
demonstrated  that  with  early  diagnosis  of  cancer  of  the  prostate,  this 
radical  procedure  should  give  splendid  results.  During  the  past  year 
three  other  cases  have  been  radically  operated  by  the  same  method  and 
the  four  cases  will  be  given  in  detail. 

Case  VII. — Carcinoma  of  prostate.  Radical  operation.  Excision  of  en- 
tire prostate,  seminal  vesicles,  ampullce  of  vasa  deferentia,  and  cuff  of 
liladder.    Recovery. 

E.  H.  G.,  aged  70  years.     Admitted  April  1,  1904.     No.  15,929. 

Complaint. — Frequency  of  urination  and  pain. 

Family  history. — Negative. 

Past  history. — Negative.    Up  to  May,  1903,  no  urinary  trouble. 

Present  illness. — In  May,  1903,  he  began  to  have  pain  in  the  glans  penis 
during  and  at  the  end  of  urination.  At  this  time  there  was  no  increased 
frequency  of  urination,  no  hematuria,  no  pain  anywhere  except  at  the  end 
of  the  penis.  In  June,  1903,  he  began  to  have  pains  in  the  bladder  at  the 
end  of  urination.  At  this  time  he  also  noticed  a  slight  increased  frequency, 
but  he  did  not  have  to  arise  more  than  once  or  twice  at  night  to  urinate. 
The  pain  at  this  time  was  so  great  that  a  physician  was  consulted  and  an 
unsuccessful  attempt  at  catheterization  made.  After  this  the  frequency 
of  urination  increased  considerably,  but,  when  catheterized  by  Dr.  M.  B. 
Tinker,  whom  he  consulted  about  July  1,  only  a  small  amount  of  residual 
urine  was  found.  Dr.  Tinker  made  a  diagnosis  of  enlarged  prostate  and 
referred  him  to  me.  During  the  summer  of  1903  he  was  treated  by  an 
"Osteopath"  with  prostatic  massage,  with  considerable  detriment;  urina- 
tion becoming  very  painful  and  frequent. 

During  the  fall  the  symptoms  steadily  grew  worse,  and  he  began  to  have 
a  slight  pain  in  the  perineum  and  thighs.  He  then  consulted  surgeons  in 
Philadelphia,  who  passed  a  catheter,  drew  off  four  ounces  of  residual  urine, 
and  on  December  8,  1903,  performed  a  Bottini  operation.  After  the  oper- 
ation urine  passed  quite  freely,  but  the  pain  in  the  glans  penis  persisted 


498  Hugh  H.  Young. 

and  the  perineal  pain  became  severe.  After  six  weeks  the  frequency  and 
difficulty  of  urination  returned,  and  since  then  has  inci'eased  until  he  now 
has  to  void  every  15  to  30  minutes.  Pain  is  constantly  present,  and  during 
urination  is  severe  in  bladder  and  penis.  No  hematuria.  Sexual  powers 
(desire,  erections,  and  emissions)  were  normal  until  May,  1903,  but  began 
to  decrease,  and  have  been  absent  since  June.  His  weight  is  about  normal. 
Examination. — Mucous  membranes  of  good  color.  Lungs  negative; 
slight  systolic  murmur  at  apex  of  heart.  Abdomen  negative.  No  glandu- 
lar enlargement.    Genitalia  normal. 

Rectal  exaviination. — Prostate  considerably  enlarged,  bulging  far  into 
the  rectum.  The  contour  is  somewhat  irregular,  surface  nodular,  consist- 
ence hard,  and  the  capsule  of  the  prostate  is  apparently  adherent  to  the 
rectum.  The  lateral  borders  of  the  prostate  are  very  declivitous.  Median 
furrow  and  notch  obliterated.  The  right  seminal  vesicle  is  palpable,  ap- 
parently distended  but  not  indurated.  In  the  region  of  the  left  seminal 
vesicle  there  is  an  oblong  indurated  mass,  probably  two  cm.  wide,  which  is 
continuous  with  the  upper  end  of  the  prostate.  A  catheter  was  introduced 
only  after  dilatation  with  filiforms  and  followers,  owing  to  a  considerable 
contracture  of  the  prostatic  urethra.  400  cc.  residual  urine  were  present. 
Urine  light  amber  color.  Microscopically,  contains  no  bacteria  or  pus 
cells. 

Gystoscopic  examination. — ^Very  little  change  in  the  mucous  membrane 
of  bladder.  The  lateral  lobes  were  not  intravesically  enlarged  and  the 
median  portion  of  the  prostate  was  only  slightly  elevated  above  the  level 
of  the  trigone  and  showed  no  marked  hypertrophy.  Obstruction  therefore 
seemed  to  be  in  the  anterior  or  middle  one-third  of  the  prostatic  urethra. 
Urinalysis. — Voided  urine;  very  slightly  cloudy;  microscopically,  a  few 
red  blood  corpuscles;  no  bacteria;  no  pus  cells. 

Note. — The  diagnosis  of  carcinoma  of  the  prostate  was  made  on  rectal 
examination,  showing  induration  of  prostate  extending  into  the  region  of 
the  left  seminal  vesicle,  and  the  absence  of  intravesical  enlargement.  The 
history  of  pain  before  any  urinary  trouble  came  on  was  considered  sug- 
gestive of  malignancy.  The  patient  was  sent  to  the  Johns  Hopkins  Hospi- 
tal and  catheterized  regularly  several  times  a  day  preliminary  to  operation. 
The  patient  was  told  that  the  prostatic  enlargement  was  cancerous,  and 
that  a  radical  operation,  in  which  the  entire  prostate  and  seminal  vesicles 
should  be  removed  in  one  piece  alone  offer  a  chance  of  cure.  No  promise 
of  good  functional  result  could  be  made,  but  the  patient  readily  acquiesced 
in  the  operation. 

THE  BADICAI.  OPEEATION. 

April  7,  1904-  Operation.  Ether.  Radical  excision  of  prostate,  seminal 
vesicles  and  cuff  of  Wadder  through  perineum.  Anastomosis  of  anterior 
wall  of  'bladder  to  membranous  urethra.  Closure  of  remainder  of  vesical 
opening. 

With  the  kind  assistance  of  Dr.  Halsted  the  operation  was  performed  as 
follows: 


An  Operation  for  Cancer  of  Prostate. 


499 


An  inverted  V  cutaneous  incision  was  made  in  the  perineum  as  in  the 
operation  employed  by  me  for  simple  hypertrophy  of  the  prostate — each 
branch  of  the  incision  being  about  two  inches  long.  By  blunt  dis- 
section the  end  of  the  bulb  and  central  tendon  were  exposed,  and 
the  latter  divided,  exposing  in  turn  the  recto-urethralis  muscle,  the  division 
of  which  gave  free  access  to  the  membranous  urethra  behind  the  triangu- 
lar ligament.     Urethrotomy  upon  a  grooved  staff  was  followed  by  intro- 


FiG.  1. — After  transverse  section  of  urethra. 


duction  of  the  prostatic  tractor,  which  was  opened  out  after  it  reached  the 
bladder.  While  traction  was  made  upon  this  instrument,  the  rectum  was 
carefully  separated  from  the  prostatic  capsule  by  blunt  dissection  until  the 
entire  posterior  surface  of  the  prostate  was  brought  into  view. 
Up  to  this  point  the  operator  proceeded  exactly  as  in  the  usual  prostat- 
ectomy operation.  The  tissues  around  the  prostate  were  more  hemorrhagic 
and  the  wall  of  the  rectum  more  closely  adherent  to  the  capsule  of  the  pros- 
tate than  usual.  Examination  of  the  prostate  then  showed  much  greater 
induration  than  I  had  ever  encountered  in  a  benign  prostate.  The  rectum 
Vol.  XIV.— 32. 


500 


Hugh  H.  Young. 


and  the  periprostatic  tissues  were  free  from  invasion.  Complete  excision 
was  therefore  decided  upon,  and  carried  out  as  follows:  The  handle  of  the 
tractor  was  depressed,  thus  exposing  the  membranous  urethra  anterior  to 
it,  where  it  was  easily  divided  transversely  with  a  scalpel,  leaving  a  small 
stump  of  the  membranous  urethra  protruding  from  the  posterior  surface 
of  the  triangular  ligament.  By  further  depressing  the  handle  of  the 
tractor  the   puboprostatic   ligament  was   exposed,   and   being  very   tautly 


Fig.  2. — Exposure  of  the  seminal  vesicles. 


drawn,  easily  divided  by  scissors,  thus  completely  severing  the  prostate 
from  all  important  attachments  (except  posteriorly),  as  shown  in  Fig.  1. 
The  lateral  attachments,  which  are  slight,  were  easily  separated  by  the 
finger.  During  these  manipulations  a  moderate  amount  of  hemorrhage 
was  encountered  (coming  from  the  periprostatic  veins,  particularly  those 
just  behind  the  triangular  ligament  in  front  of  the  prostate),  but  it  was 
easily  controlled  by  clamping  several  bleeding  points,  and  applying  pres- 
sure with  gauze  by  means  of  an  anterior  deep  retractor  (see  Fig.  3). 

The  posterior  surface  of  the  seminal  vesicles  were  then  freed  by  blunt 
dissection,  the  now  mobile  prostate  being  drawn  well  out  of  the  wound,  as 


An  Operation  for  Cancer  of  Prostate. 


501 


shown  in  Fig.  2.  In  this  exposure  of  the  posterior  surface  of  the  vesicles 
I  was  careful  not  to  break  through  the  fascia  of  Denonvilliers,  which  covers 
not  only  the  posterior  surface  of  the  prostate  but  also  of  the  seminal 
vesicles,  which  forms,  I  believe,  an  important  barrier  to  the  backward 
growth  of  the  disease. 

The  next  step  was  to  expose  the  anterior  surface  of  the  bladder,  which 
was  easily  done  by  depressing  the  tractor  and  making  strong  traction. 


/^ 

'        \ 

^\ 

//       •  v.^^B 

PIBF' 

m\ 

■"^^-—^ 

m^^K^^ 

^BK 

■^mM. 

-^ 

^■■ifiB^^^^^K,       // 

^^^^^^^HB  ^y 

f  f? 

f 

M 

/ 

Fig.  3. — Incision  into  bladder  just  above  prostate. 


By  this  procedure  the  bladder  was  drawn  down  so  close  to  the  skin  wound 
that  it  was  easily  incised  at  a  point  in  the  middle  line  about  1  cm.  above 
the  prostato-vesical  juncture,  as  shown  in  Fig.  3. 

By  means  of  scissors  the  division  was  continued  on  each  side  until  the 
trigone  was  exposed.  Fig.  4.  After  swabbing  away  the  blood  and  urine 
the  ureters  were  easily  found  and  the  line  of  incision  carried  across  the 
trigone  with  a  scalpel  so  as  to  pass  about  1  cm.  in  front  of  the  ureteral 
orifices. 

While  still  making  traction  upon  the  prostate,  the  base  of  the  bladder 
was  pushed  upward  with  the  handle  of  the  scalpel,  thus   exposing  the 


502 


Hugh  H.  Young. 


anterior  surface  of  the  seminal  vesicles  and  the  adjacent  vasa  deferentia 
(Fig.  5),  all  of  which  were  carefully  freed  by  blunt  dissection  with  the 
finger  as  high  up  as  possible,  so  as  to  remove  with  the  vesicles  as  much 
circumjacent  fat  and  areolar  tissue  as  possible  on  account  of  the  lym- 
phatics which  they  contained.  The  vasa  deferentia,  after  being  drawn 
down  as  far  as  possible,  were  picked  up  on  a  small  blunt  hook  and  divided 
with  scissors  high  up,  care  being  exercised  to  see  that  the  ureters  were 


Fig.  4. — Exposure  and  division  of  trigone. 


not  in  danger.  After  division  of  the  vasa  the  seminal  vesicles  were 
found  to  come  down  more  readily,  and  the  deep  adhesions  were  finally 
divided,  and  the  mass  shown  in  the  photograph  (Fig.  6)  removed.  As 
seen  here  in  the  side  view,  a  portion  of  the  membranous  urethra,  the  entire 
prostate  with  its  capsule  intact,  the  seminal  vesicles,  4  cm.  of  the  vasa 
deferentia,  and  a  cuff  of  the  bladder  1  cm.  wide  along  the  anterior  and 
lateral  surfaces  and  2  cm.  wide  in  the  region  of  the  trigone,  have  been 
removed  in  one  piece.  Fig.  7  shows  the  posterior  view  of  the  tissues 
removed. 

There  now  remained  a  large  defect  to  be  repaired.  The  vesical  opening 
was  about  8  cm.  in  diameter  and  had  sunk  far  back  into  the  depths.  The 
stump  of  membranous  urethra  had  been  obliterated  by  the  compression  of 


An  Operation  for  Cancer  of  Prostate. 


503 


the  anterior  retractor  so  that  it  was  necessary  to  insert  a  soft  rubber  cath- 
eter through  the  urethra  from  the  meatus  to  discover  it.  The  anterior  wall 
of  the  vesical  opening  was  then  caught  with  forceps,  and  with  no  great 
traction  I  was  surprised  to  find  how  easily  it  could  be  drawn  down  to  the 
membranous  urethra,  where  an  anastomosis  was  readily  made,  as  shown 
in  Fig.  8.  The  first  suture  was  placed  by  inserting  the  needle  into  the 
triangular  ligament  above  the  urethra  and  out  through  the  anterior  wall 


Fig.  5. — Final  separation  of  seminal  vesicles  and  division  of  vasa. 


of  the  membranous  urethra,  then  through  the  anterior  wall  of  the  bladder 
in  the  median  line,  from  within  out,  care  being  taken  to  include  only  the 
submucosa  and  muscle.  When  this  suture  was  tied  the  median  line  of  the 
anterior  wall  of  the  bladder  was  drawn  to  meet  the  median  line  of  the 
roof  of  the  remaining  membranous  urethra,  the  knot  being  outside,  and 
the  thread  left  long.  Fig.  9  shows  diagrammatically  the  plan  of  vesico- 
urethral anastomosis  described  above. 

Lateral  sutures,  similarly  placed  (including  the  periurethral  muscular 
structures  below),  and  two  posterior  sutures  completed  the  anastomosis 
of  the  membranous  urethra  with  a  small  ring  into  which  the  anterior 


504 


Hugh  II.  Young. 


Fig.  6. — Photograph  of  specimen.     Side  view. 


yfiS 


i-<S7' 


V/j« 


Fig.  7. — Photograph  of  specimen.     Posterior  view. 


An  Operation  for  Cancer  of  Prostate. 


505 


portion  of  the  margin  of  the  vesical  wound  had  been  fashioned  by  the  tying 
of  the  sutures,  as  shown  in  Fig.  8.  The  remainder  of  the  vesical  wound 
now  presented  as  a  longitudinal  opening,  which  was  easily  closed  by 
sutures,  placed  as  shown  in  Fig.  8,  thus  completely  closing  the  defect 
and  replacing  the  prostatic  urethra  with  a  funnel-shaped  process  made 
from  the  bladder  wall. 

The  sutures  used  were  silk,  one  end  of  each  being  left  long  and  brought 


Fig.  8. — The  anastomosis  of  anterior  wall  of  bladder  to  urethra  has  been 
made.    The  rest  of  vesical  opening  is  being  closed. 


out  of  the  wound  so  that  they  could  be  extracted  later  (since  then  I  have 
found  alternate  sutures  of  catgut  and  silk-worm  gut,  also  left  long,  the 
best).  After  light  gauze  packing  had  been  placed  in  various  portions  of 
the  wound,  the  levator  ani  muscles  were  drawn  together  with  catgut 
(two  sutures)  in  front  of  the  rectum  and  the  skin  wound  closed  on  each 
side  with  interrupted  catgut  sutures,  leaving  only  a  small  portion  open  at 
the  angle  in  front  for  exit  of  the  gauze  drainage. 

The  retained  rubber  catheter  (which  was  of  considerable  service  in 
making  the  anastomosis  of  the  urethra  and  bladder)  was  fastened  in  place, 
by  adhesive  plaster  around  the  penis,  and  the  patient  was  returned  to 
the  ward. 


506 


Hugli  H.  Young. 


During  the  operation  he  received  1000  cc.  salt  solution  infused  beneath 
the  breast,  and  his  condition  throughout  was  good,  pulse  varying  from  65 
to  92,  and  SO  at  the  end  of  the  operation,  which  required  two  hours. 

DESCKIPTION   OF   SPECIMEN  BEMOVED  AT   OPERATION. 

Oross  description. — Specimen  consists  of  prostate,  prostatic  urethra, 
seminal  vesicles,  a  cuff  of  the  bladder  including  the  anterior  portion  of  the 
trigone,  and  the  ampullae  of  both  vasa  deferentia  (Figs.  6,  7). 


Fig.  9. — Diagram  showing  plan  of  vesico-urethral  anastomosis. 


Prostate  is  smooth,  symmetrical,  moderately  enlarged,  measures  5  x  41/4 
cm.  Its  lateral  edges  are  distinct  and  its  surface  has  been  cleanly  dis- 
sected from  surrounding  tissues.  Its  upper  limit  on  the  left  side  merges 
into  the  vesical,  but  on  the  right  side  there  is  a  groove  between  the  lower 
limit  of  the  vesical  and  the  upper  limit  of  the  prostate.  There  is  no 
median  groove  nor  definite  notch.  On  section  the  prostate  consists  of  firm, 
white,  fairly  homogenous  tissue.  Here  and  there  can  be  seen  areas  where 
the  glandular  structure  is  more  apparent,  but  the  general  picture  on  cross 
section  is  that  of  fibrous  tissue. 

Vesicles. — On  the  right  side  the  vesicle  is  continuous  with  the  prostate, 
and  is  quite  hard  to  the  palpating  finger.     On  the  left  side  it  stands  out 


An  Operation  for  Cancer  of  Prostate.  507 

as  a  distinct  separate  structure  and  is  soft  on  palpation.  The  tissue  be- 
tween the  vesicles  is  firm,  but  does  not  stand  up  as  a  definite  ridge.  How- 
ever, the  notch  of  the  prostate  and  the  tip  of  the  intervesicular  space  are 
obliterated  by  bulging  of  the  carcinomatous  growth.  The  right  vesical, 
on  section,  is  itself  normal  and  not  invaded  by  the  tumor.  On  the  left 
side  the  growth  has  extended  much  more  towards  the  vesicle,  and  in  a 
section  across  the  middle  of  the  vesicle  the  anterior  wall  of  the  vesicle  is 
seen  to  be  invaded  by  the  growth  which  lies  between  it  and  the  trigone, 
but  the  posterior  surface  of  the  vesicle  is  normal  in  appearance  and  its 
cavity  is  not  invaded.  The  vas  deferens  on  each  side  has  been  removed 
for  a  distance  of  about  4  cm.,  and  at  point  of  section  each  appears  healthy. 
An  apparently  encapsulated  mass  of  carcinoma  extends  up  along  the  outer 
side  of  the  left  vas  deferens  to  within  1  cm.  of  its  upper  end,  and  it  seems 
probable  that  the  tumor  has  not  been  given  a  sufficiently  wide  berth  here. 
The  cuff  of  the  bladder  removed  with  the  prostate  measures  from  2  to  3 
cm.  wide.  It  is  apparently  free  from  neoplastic  invasion  except  in  the 
anterior  portion  of  the  trigone,  where  it  is  adherent  to  the  intervesicular 
mass  of  carcinoma  and  is  apparently  invaded.  The  mucous  membrane  is 
everywhere  intact,  and  at  point  of  excision  the  bladder  seems  healthy. 

Study  of  the  stained  sections  shows  the  entire  prostate  to  be  replaced  by 
adenocarcinoma,  in  most  places  as  a  solid  type  (carcinoma  solidum).  The 
prostatic  capsule  has  not  been  penetrated  by  the  carcinoma,  quite  a  wide 
intact  area  of  fibrous  tissue  being  present.  The  urethra  has  not  been 
invaded  but  the  ejaculatory  ducts  are  completely  plugged  with  carcinoma 
cells,  and  this  condition  is  present  for  a  considerable  distance  along  the 
vasa  deferentia,  but  the  upper  ends  are  free.  The  tumor  has  not  pene- 
trated the  capsule  of  the  seminal  vesicle  as  supposed,  and  both  vesicles 
are  free  from  disease,  but  between  them  and  the  bladder'  just  above  the 
upper  end  of  the  prostate  a  mass  of  carcinoma  about  1  cm.  wide  is  seen. 
In  the  muscle  of  the  anterior  part  of  the  trigone  several  lymphatics  with 
cancer  cells  are  seen  but  at  the  upper  limit  the  bladder  wall  is  healthy. 

Convalescence:  April  8. — Patient  reacted  well.  Pulse  90.  Temperature 
98.2°. 

April  J^.— Patient  has  done  well  since  the  operation.  All  gauze  has 
been  removed  from  the  perineal  wound  and  the  catheter  is  out  of  the 
urethra.     Urine  escapes  through  perineum. 

April  21. — Patient  doing  well.  To-day  passed  a  little  urine  through  the 
urethra. 

April  30. — Considerable  urine  comes  through  the  urethra.  Silk  sutures 
(fastening  bladder  to  urethra)   still  hold  firmly  and  cannot  be  pulled  out. 

May  20. — General  condition  excellent.  Patient  walks  about  and  sits  up 
every  day.  All  silk  sutures  have  been  removed.  He  is  free  from  pain 
and  there  is  only  a  slight  leakage  of  urine  through  the  perineum.  Some- 
times he  goes  two  to  three  hours  without  voiding. 

May  23. — Perineal  wound  closed  tight,  all  urine  comes  through  the  penis. 
General  condition  excellent. 
Vol.  XIV.— 33. 


508  Hiigli  H.  Young. 

May  30. — Patient  discharged  from  hospital.  At  night  he  can  hold  urine 
for  several  hours  until  the  desire  to  urinate  comes  on  when  he  empties  his 
bladder.  Does  not  wet  the  bed.  During  the  day  the  urine  is  apt  to  dribble 
away,  but  this  is  controlled  by  a  padded  jock-strap. 

July  25. — Letter:  "  I  have  steadily  gained  in  strength.  Can  now  work 
for  several  hours  with  comparative  comfort.  Am  troubled  with  incon- 
tinence in  the  day  but  do  not  wet  the  bed  at  night." 

December  22. — Patient  improved  steadily  for  five  months  after  the  oper- 
ation. Intervals  between  urinations  becoming  longer  and  incontinence 
graduallj'  diminishing.  In  October  he  began  to  suffer  pain  at  the  end  of 
the  penis  during  urination.  His  general  health  is  excellent  and  he  weighs 
170  pounds  again.     He  has  no  pain  in  back  or  limbs. 

Examination. — Patient  in  excellent  physical  condition.  Abdomen,  groins, 
and  genitalia  negative.  Rectal  examination  shows  small  amount  of  indu- 
ration in  the  region  of  the  operation.  On  the  left  side  high  up  a  narrow 
elongated  indurated  mass,  about  as  wide  as  a  lead  pencil  and  extending  out 
towards  the  spine  of  the  ischium,  is  felt.  Its  contour  is  round,  surface 
smooth,  and  there  is  no  infiltration  around  it.  Its  position  is  that  of  the 
vas  deferens.  Silver  catheter  meets  an  obstruction  about  the  triangular 
ligament,  but  filiforms  pass  with  ease,  and  dilating  followers  are  easily 
introduced.  A  stone  is  felt  in  the  bladder.  The  bladder  capacity  is  110 
cc.  the  tonicity  good.  The  cystoscope  shows  two  small  stones  in  a  shallow 
pouch  on  the  right  side  of  the  bladder,  and  just  behind  the  triangular  liga- 
ment a  small  stone,  which  is  attached  to  a  silk  ligature,  is  seen  in  the 
bladder  cavity.  The  urethral  outlet  of  the  bladder  is  in  the  shape  of  a 
funnel,  the  mucous  membrane  being  thrown  into  hypertrophied  folds. 
The  ureteral  orifices  cannot  be  made  out. 

Decemter  23. — Operation.  Ether.  Litholapaxy.  Two  of  the  stones 
were  easily  crushed  and  removed,  but  the  one  which  was  attached  to  the 
ligature  in  the  floor  of  the  bladder  could  not  be  removed  with  the  litho- 
trite;  it  was  finally  extracted  through  the  urethra  by  means  of  a  long 
curved  clamp,  the  ligature  and  a  small  bit  of  mucous  membrane  coming 
with  it. 

December  30. — On  the  day  after  the  operation  patient's  temperature  arose 
to  103.3°,  but  since  then  has  gradually  decreased  and  is  now  about  normal. 
There  has  been  considerable  tenderness  over  the  bladder  since  the  opera- 
tion, but  this  is  slowly  decreasing.  (The  writer  had  pneumonia  at  this 
time.) 

January  1,  1905. — The  perineum  has  become  quite  swollen  and  tender, 
and  to-day  a  urinary  fistula  opened  up  in  the  site  of  the  old  scar. 

January  8. — An  indurated  mass  is  present  on  the  right  side  of  the 
bladder.  Tenderness  here  is  acute.  Perineal  sinus  draining  freely. 
Catheter  passed  and  bladder  washed  out. 

January  9. — Operation.  Incision  and  drainage  of  perivesical  abscess  of 
right  side.  A  large  cavity  containing  pus  and  foul  smelling  urine  was 
found  communicating  with  the  bladder  on  the  right  side  through  a  necrotic 
opening. 


An  Operation  for  Cancer  of  Prostate.  509 

January  i5.— Patient  has  improved  rapidly.     Temperature  normal. 

January  20. — Patient  became  suddenly  worse  yesterday.  Drowsy,  nau- 
seated, temperature  subnormal.  To-day  he  gradually  grew  worse  and 
died  at  7  a.  m. 

Autopsy. — The  bladder  is  much  contracted  but  the  healing  between  it 
and  the  urethra  has  been  excellent.  There  is  no  sign  of  recurrence  in 
the  bladder.  The  kidneys,  ureters,  and  urethra  normal  (prostatic  urethra 
absent.  There  was  no  sign  of  recurrence  or  of  glandular  metastases  any- 
where to  be  made  out,  but  just  back  of  the  bladder  a  small  indurated  area 
about  1  cm.  in  size  was  present  and  a  section  of  this  shows  carcinoma. 
The  bladder  and  rectum  were  both  healthy.  A  large  abscess  cavity  con- 
necting with  the  perineum  and  bladder  on  the  right  side  was  present. 

Case  VIII. — Carcinoma  of  prostate  involving  seminal  vesicle.  Radical 
excision  of  prostate,  vesicles,  vasa  and  cuff  of  bladder.  Recovery.  Subse- 
quent death  from  uremia. 

W.  R.,  aged  64,  admitted  September  14,  1904.     No.  16,675. 

Onset  with  increased  frequency  of  urination  three  years  ago.  Frequency 
and  difficulty  of  urination  has  gradually  increased  until  three  weeks  ago 
patient  was  voiding  10  to  12  times  during  the  day;  no  pain  present.  Com- 
plete retention  of  urine  for  the  first  time  one  week  ago.  No  history  of 
hematuria.  Has  lost  very  little  in  weight.  For  the  past  week  catheteri- 
zation has  been  necessary. 

Examination. — A  well-nourished  man  with  mucous  membranes  of  good 
color.  General  physical  examination  negative;  no  enlarged  glands  to  be 
felt.     Genitalia  normal. 

Rectal  examination. — Prostate  is  moderately  enlarged,  the  left  being 
larger  than  the  right  lobe.  The  surface  is  smooth,  consistence  hard,  in- 
elastic, but  not  nodular.  The  induration  is  general  over  the  entire  posterior 
surface  of  the  prostate.  There  is  no  enlargement  or  induration  in  the 
region  of  either  seminal  vesicle,  but  in  the  space  between  the  two  there 
is  a  distinct  plateau  of  induration  extending  1  or  2  cm.  above  the  upper 
limits  of  the  prostate.  Above  this  the  tissues  feel  soft.  No  indurated 
glands  or  lymphatics  are  to  be  felt  in  the  region  of  the  seminal  vesicles 
along  the  lateral  walls  of  the  pelvis  or  in  the  sacral  fossa.  The  rectal 
mucosa  is  soft,  not  adherent,  not  ulcerated. 

Cystoscopic  examination. — Catheter  passes  easily.  Bladder  capacity  300 
cc.  (bladder  at  present  irritable).  Cystoscope  shows  a  slight  intravesical 
enlargement  of  the  median  portion  of  the  prostate  which  is  continuous 
with  an  elevation  or  thickening  in  the  anterior  part  of  the  trigone.  The 
lateral  lobes  of  the  prostate  are  slightly  enlarged,  and  between  them  in 
front  is  a  shallow  cleft.  Both  ureters  are  easily  seen  and  normal  in  ap- 
pearance. The  mucous  membrane  covering  the  prostate  around  the 
orifice  and  the  trigone  is  everywhere  healthy  in  appearance.  The  bladder 
wall  is  trabeculated  slightly  but  otherwise  normal  in  appearance.  No 
evidence  of  vesical  neoplasm.  With  the  finger  in  the  rectum  and  cysto- 
scope in  the  urethra  the  median  portion  of  the  prostate  is  considerably 
Vol.  XIV.— 34. 


510  Hugh  H.  Young. 

thicker  than  normal  and  above  the  prostate  beneath  the  trigone  is  a  small 
indurated  mass.     No  induration  in  the  region  of  either  seminal  vesicle. 

Note. — The  diagnosis  of  carcinoma  of  the  prostate  was  made  here  upon 
induration,  the  intervesicular  mass,  and  the  absence  of  intravesical  hyper- 
trophy. 

Operation,  September  23,  1904. — Total  excision  of  prostate  and  seminal 
vesicles,  a  portion  of  the  vasa  deferentia,  the  entire  trigone  including  the 
ureteral  orifices  and  a  small  cuff  of  the  bladder. 

The  operation  was  done  exactly  as  in  Case  VII.  When  the  posterior 
surface  of  the  prostate  was  exposed  it  was  found  on  palpation  to  be  so 
densely  indurated  that  a  positive  diagnosis  was  made  without  cutting  into 
it.  "When  the  trigone  was  exposed,  after  an  incision  through  the  anterior 
and  lateral  wall  of  the  bladder,  palpation  showed  an  indurated  condition 
of  the  musculature  of  the  trigone  which  seemed  to  extend  up  to  the  region 
of  the  ureteral  orifice.  It  was  therefore  thought  advisable  to  excise  the 
ureteral  papillae  and  a  portion  of  the  posterior  wall  of  the  bladder  imme- 
diately above  the  trigone.  A  portion  of  the  intramural  course  of  the 
ureter  was  left  undisturbed  and  it  was  hoped  that  this  would  leave  suffi- 
cient sphincter  on  each  side  to  prevent  an  ascending  infection.  No  diffi- 
culty was  experienced  in  excising  the  seminal  vesicles,  about  4  cm.  of  the 
right  vas  and  6  cm.  of  the  left  vas  along  with  the  prostate,  as  shown  in 
the  accompanying  photograph  of  the  posterior  surface  (Fig.  16).  Anasto- 
mosis of  bladder  to  stump  of  membranous  urethra  was  easily  performed, 
catgut  being  used  in  this  case  (on  account  of  the  difficulty  of  removing 
the  silk  in  Case  VII).  Submammary  infusion  of  salt  solution  during  the 
operation.    Patient  stood  operation  well.     Pulse  at  end  85. 

Examination  of  specimen. — Specimen  consists  of  the  entire  prostate, 
prostatic  urethra,  trigonum,  anterior  and  lateral  walls  of  the  bladder,  both 
seminal  vesicles,  514  cm.  of  the  left  and  4%  cm.  of  the  right  vas  deferens, 
and  a  separate  piece  of  tissue,  4x4  cm.  in  size,  from  the  base  of  the 
bladder.  The  vesical  muscle  here  feels  hard,  but  the  mucosa  appears  nor- 
mal and  section  of  the  muscle  does  not  show  definite  carcinoma.  The 
prostate  is  surrounded  by  smooth  unchanged  capsule.  The  consistence  is 
very  hard,  but  there  are  no  nodules.  On  section  the  tissue  is  smooth, 
shining,  fibrous,  hard  to  cut,  but  not  gritty  and  specked  here  and  there 
with  small  yellowish  pin-point  to  pin-head  areas  intermixed  with  a  fibrous 
stroma.  On  the  right  side  the  growth  has  not  extended  towards  the 
bladder,  except  at  the  anterior  portion,  just  under  the  capsule,  where  it 
has  almost  reached  the  vesical  mucosa.  On  the  left  side  it  has  just 
stopped  short  of  the  bladder,  having  apparently  passed  through  the  pros- 
tatic capsule.  The  mucosa  of  the  trigone  is  apparently  normal  and  un- 
invaded,  and  while  the  muscle  feels  indurated  and  pale  in  color  it  is  not 
definitely  carcinomatous.  The  seminal  vesicles  are  both  soft,  filled  with 
yellowish,  glairy  fluid,  and  apparently  normal  on  section.  The  left  vas 
deferens  is  indurated  and  thickened  near  its  junction  with  the  seminal 
vesicle.     Section  at  various  points  shows  a  normal  appearance.     The  right 


An  Operation  for  Cancer  of  Prostate.  511 

vas  deferens  is  thickened  but  otherwise  normal.  After  hardening  in 
alcohol,  transverse  serial  sections  of  the  specimen  were  made.  These 
show  the  urethra  to  be  circularly  constricted  but  uninvaded.  The  carci- 
noma has  invaded  the  space  between  the  seminal  vesicles  and  tb-e  trigone, 
and  microscopic  sections  show  that  the  anterior  portion  of  the  trigone 
has  been  invaded  by  the  neoplasm,  and  that  the  lower  portions  of  the  vasa 
deferentia  are  involved.  Sections  from  the  bladder  wall  in  the  region  of 
the  ureters  show  no  carcinoma,  and  it  is  evident  that  the  disease  has  been 
thoroughly  removed  with  a  wide,  healthy  area  above.  The  entire  specimen 
weighs  g.  110,  measures  6  x  8  x  S^/^  cm. 

Microscopical  examination. — Section  from  the  prostate  about  the  middle 
of  the  prostatic  urethra  shows  an  adenocarcinoma.  The  acini  are  nearly 
all  small,  at  times  numbers  being  closely  packed  together  and  separated 
by  rather  thin  bands  of  stroma.  The  acini,  however,  in  none  of  the  areas 
simulate  very  closely  normal  culs-de-sac.  There  is  a  great  tendency  for 
the  carcinoma  to  infiltrate  between  the  bands  of  stroma,  and  in  considerable 
areas  it  loses  almost  entirely  its  adenomatous  character  and  becomes  of  an 
infiltrating  type.  Occasionally  solid  carcinoma  tubules  are  encountered. 
The  epithelium  varies  greatly  in  character,  that  lining  the  acini  being 
mostly  of  a  cylindrical  type.  In  the  infiltrating  portions  the  epithelial 
cells  are  quite  polymorphous.  The  nuclei  show  great  variations,  at  times 
very  small,  again  large,  and  at  other  times  extremely  large.  The  contour 
is  mostly  round,  although  they  may  be  very  irregular  in  shape.  Sections 
from  the  bladder  wall  in  the  region  of  the  trigone  and  from  the  upper 
portion  of  the  left  seminal  vesicle,  and  from  different  portions  of  the 
periprostatic  tissue  are  negative  for  carcinoma.  The  malignant  growth  is 
an  adenocarcinoma  with  a  marked  tendency  to  infiltration. 

Convalescence. — September  29,  six  days  after  operation.  Patient  con- 
valesced poorly.  There  was  considerable  nausea  for  three  days  but  no 
fever.  The  gauze  drains  were  removed  on  the  third  day.  The  urethral 
catheter  has  not  drained  at  all. 

October  6. — General  condition  improving,  but  patient  is  mentally  erratic. 
Considerable  dermatitis  around  perineal  wound. 

October  13. — Patient  has  gained  decidedly  in  weight  and  strength. 
Wound  dirty. 

October  20. — Patient  has  not  gained  during  the  past  week;  has  no  rise 
of  temperature,  but  is  restless.     Dermatitis  much  improved. 

November  5. — General  condition  apparently  failing.  Appetite  poor. 
Perineal  wound  widely  patent,  draining  considerable  foul  alkaline  mucous. 

November  8. — Since  last  note  the  patient  has  failed  gradually  but  stead- 
ily. He  is  unable  to  take  nourishment,  has  had  several  severe  night 
sweats.  Temperature  subnormal.  No  definite  signs  of  uremia,  but  his 
pulse  is  very  weak.     Later,  patient  died  during  the  night. 

Autopsy,  November  9. — Anatomical  diagnosis:  Perineal  wound,  diph- 
theritic and  hemorrhagic  cystitis,  ureteritis  and  pyelitis.     Arterio-sclerosis. 


512  Hugh  H.  Young. 

Chronic  diffuse  nephritis.  Cardiac  hypertrophy  and  dilatation.  Chronic 
myocarditis,  endocarditis,  and  emphysema  of  lungs.  Chronic  perihepat- 
itis, splenitis,  pancreatitis. 

The  perineal  wound  leads  into  a  cavity  lined  with  granulation  tissue 
and  in  direct  communication  with  the  bladder,  which  has  a  large  opening 
in  its  inferior  aspect.  The  anterior  wall  of  the  bladder  is  continuous  with 
the  urethra,  the  sutured  portion  in  this  region  having  united.  The  pos- 
terior sutures  have  evidently  broken  down.  The  connection  between  the 
urethra  and  the  bladder  shows  no  evidence  of  stricture.  The  right  ureteral 
orifice  is  covered  by  a  small  calcareous  mass,  which  is  closely  adherent  to 
it.  The  left  ureteral  orifice  cannot  be  found,  apparently  opening  at  the 
wound.  The  kidney  and  pelvis  show  acute  inflammation  with  exudate. 
False  membranes  cover  the  calices.  An  acute  ureteritis  is  present  on  both 
sides.  It  is  evident  that  there  has  been  an  ascending  infection  from  the 
bladder.  Careful  examination  failed  to  reveal  any  carcinoma.  The  re- 
gion of  the  wound,  the  rectum,  the  bladder,  and  the  other  pelvic  struc- 
tures show  no  carcinoma,  no  metastatic  glands.  Sections  for  microscopic 
study  were  taken  from  the  left  vas  deferens  near  its  lower  end,  the 
bladder  wall  near  the  left  ureteral  orifice,  the  rectum  posterior  to  the 
wound,  and  the  right  vas  deferens.  There  is  no  evidence  of  carcinoma 
in  any  of  these  sections. 

Note. — From  a  careful  study  of  the  specimen  removed  at  operation  and 
the  autopsy  it  is  evident  that  the  malignant  disease  had  been  completely 
removed.  The  extensive  excision  of  the  base  of  bladder,  including  the 
ureteral  orifices,  was  not  necessary  and  unquestionably  led  to  the  ascend- 
ing infection  which  caused  the  death  of  the  patient.  The  use  of  catgut 
proved  a  mistake,  as  it  led  to  rapid  breaking  down  of  the  wound. 

Case  IX. — Cancer  of  prostate  involving  seminal  vesicles  and  anterior 
portion  of  the  trigone.  Radical  excision  of  prostate,  seminal  vesicles,  cuff 
of  bladder,  ampullce  of  vasa  deferentia.  Recovery.  Restoration  of  urina- 
tion through  urethra.    Well  thirteen  months  after  operation. 

S.  R.  B.,  aged  65  years,  admitted  February  4,  1905.     Of.  No.  829. 

Four  years  ago  the  patient  began  to  have  slight  frequency  of  urination, 
which  has  increased  gradually  until  he  now  voids  at  times  as  often  as 
six  times  in  an  hour.  Has  never  had  complete  retention  of  urine,  nor 
has  he  been  catheterized.  Has  never  had  hematuria.  For  two  years  has 
had  an  intermittent  pain  in  the  left  hip  radiating  down  to  the  knee,  some- 
times on  the  outer  side  and  sometimes  on  the  inner  side.  During  urina- 
tion there  is  a  slight  pain  in  the  region  of  the  pubes.  He  has  a  constant 
dull  pain  in  the  back,  bladder,  perineum,  and  rectum.  His  sexual  powers 
were  good  up  to  four  months  ago.     He  has  not  lost  weight. 

Examination. — Patient  is  well  nourished.  Mucous  membranes  of  good 
color.  No  glands  palpable  in  neck,  axilla,  groin,  or  pelvis.  Heart  and 
lungs  negative.    Abdomen  negative.    Genitalia  negative. 

Rectal    examination. — Prostate    is    considerable    enlarged,    both    lateral 


An  Operation  for  Cancer  of  Prostate.  513 

lobes  project  towards  the  rectum  and  the  edges  are  precipitous.  General 
contour  rounded,  smooth,  consistence  very  hard  and  incompressible  even 
on  considerable  pressure.  At  the  upper  end  of  the  prostate,  on  each  side, 
there  is  an  indurated  mass  occupying  the  area  of  the  seminal  vesicle  and 
running  upward  and  outward,  and  in  the  median  line  between  these  two 
there  is  a  small  connecting  plateau  of  indurated  tissue,  the  upper  edge  of 
which  presents  a  smooth,  concave  border.  The  examining  finger  can 
apparently  reach  above  the  area  of  the  induration.  It  is  easy  to  pass  it 
in  the  median  line  and  the  bladder  above  it  feels  soft,  but  on  the  left  side 
above  the  upper  end  of  the  seminal  vesicle  the  tissues  feel  tense,  but  no 
nodules  and  no  definite  induration  are  to  be  felt  in  this  region.  The  rectal 
mucosa  is  soft  and  not  adherent. 


Fig.  10.- — Lateral  view  of  specimen  from  Case  VIII.  Case  II,  side  view 
prostate  and  vesicle. 

Cystoscopic  examination. — Coude  silk  catheter  passes  with  ease.  500  cc. 
residual  urine  found  present.  The  cystoscope  shows  a  healthy  vesical 
mucous  membrane,  considerable  trabeculation,  especially  of  the  posterior 
wall.  The  ureteral  orifices  are  normal  in  appearance.  The  prostatic 
orifice,  shows  slight  enlargement  of  the  median  portion,  continuous  with- 
out intervening  clefts,  with  very  slightly  enlarged  lateral  lobes,  between 
which  there  is  no  cleft  in  front.  With  the  cystoscope  looking  down- 
ward and  the  handle  depressed,  the  trigone  can  barely  be  seen  over  the 
median  portion  of  the  prostate.  By  gradually  elevating  the  handle 
of  the  cystoscope  the  Interureteral  bar  and  a  portion  of  the  trigone 
becomes  visible,  but  the  anterior  portion  of  the  trigone  is  concealed 
behind  the  median  enlargement.  The  mucous  membrane  covering  the 
prostate  and  trigone  is  smooth;  no  ulceration;  no  intravesical  tumor; 
no  suggestion  of  involvement  of  the  bladder  wall.  With  the  finger  in  the 
rectum  and  cystoscope  in  the  urethra  there  is  considerable  thickness  in 
the  median  portion  and  it  is  impossible  to  feel  with  accuracy  the  beak  of 
the  instrument  in  the  bladder. 


514  Hugh  E.  Young. 

The  diagnosis  of  carcinoma  of  the  prostate  was  made  upon  the  presence 
of  induration  involving  the  seminal  vesicles  and  the  area  between  them, 
the  absence  of  much  intravesical  prostatic  enlargement  and  pain.  A 
radical  operation  was  therefore  decided  upon. 

February  16,  1905. — Operation.  Ether.  Excision  of  the  entire  prostaie, 
cuff  of  ttie  bladder  including  most  of  the  trigone,  both  seminal  vesicles  and 
vasa  deferentia.  The  prostate  was  exposed  as  in  the  usual  prostatectomy 
operation  and  tractor  inserted  through  the  membranous  urethra.  Palpation 
of  the  prostate  showed  marked  induration  and  one  very  hard  nodule  on 
the  posterior  surface.  The  diagnosis  was  considered  sufficiently  positive 
not  to  cut  into  the  prostate.  A  radical  operation  was  then  done  according  to 
the  method  described  in  Case  VII.  The  lower  end  of  the  left  ureter  was 
unintentionally  divided  at  its  junction  with  the  bladder,  the  entire  intra- 
mural portion  being  removed  along  with  the  trigone  (this  accident  was 
due  to  the  use  of  straight  scissors  instead  of  curved  ones  while  dividing 
the  lateral  wall  of  the  bladder).  The  incision  across  the  trigone  was 
made  with  a  knife  and  the  lower  end  of  the  right  ureter  was  spared.  The 
seminal  vesicles,  and  4  or  5  cm.  of  the  vasa  deferentia,  were  removed 
along  with  the  prostate  in  one  piece.  Anastamosis  of  the  divided  left 
ureter  into  the  bladder  wall  was  easily  made  by  poking  a  hole  through 
the  bladder  with  a  small  artery  forcep,  at  a  point  about  2  cm.  above  the 
vesical  wound,  grasping  the  cut  end  of  the  ureter  and  drawing  it  through 
the  hole.  It  was  held  in  place  by  means  of  two  small  catgut  sutures  in 
the  bladder  and  one  fine  silk  suture  outside  of  the  bladder.  The  bladder 
was  easily  drawn  down  and  anastamosed  with  the  stump  of  the  mem- 
branous urethra,  silk  worm  gut  being  used  for  this  purpose.  The  rest  of 
the  vesical  opening  was  closed  with  alternate  silk  worm  gut  and  catgut 
sutures,  one  end  of  each  suture  being  left  long  so  as  to  project  from  the 
wound  to  facilitate  subsequent  removal. 

Description  of  specimen. — It  consists  of  prostatic  urethra,  both  seminal 
vesicles,  portions  of  the  vasa  deferentia,  most  of  the  trigone  including 
the  left  ureteral  ridge  and  1%  cm.  of  the  lower  end  of  the  left  ureter. 
The  prostate  is  smooth,  symmetrical,  moderately  enlarged  (measures 
5x5x3  cm.).  The  upper  limit  of  each  lateral  lobe  merges  into  the  sem- 
inal vesicles,  both  .of  which  are  enlarged,  and  between  the  seminal  vesicles 
is  a  mass  also  continuous  with  the  prostate,  as  shown  in  the  accompany- 
ing photograph  (Fig.  11).  The  consistence  of  the  prostate  is  very  hard  and 
resistant  but  homogeneous.  The  right  seminal  vesicle  was  quite  hard, 
cord-like,  and  continuous  with  the  intervesicular  mass.  The  left  is  soft 
but  the  tissue  beneath  is  indurated.  The  posterior  surfaces  of  the  vesicles 
and  the  prostate  are  smooth,  and  the  neoplasm  has  apparently  been  com- 
pletely removed.  The  cuff  of  bladder  wall  removed  with  the  prostate 
measures  from  2  to  4  cm.  in  width,  being  widest  in  the  trigone,  where  it 
contains  the  intramural  portion  of  the  left  ureter.  The  mucous  membrane 
covering  it  is  smooth  and  there  is  no  appearance  of  involvement.  Numer- 
ous transverse  serial  sections  have  been  made  of  the  hardened  specimen. 


An  Operation  for  Cancer  of  Prostate.  515 

The  section  is  white  with  small  grayish  dots  and  lines.  It  is  distinctly 
fibrous  in  feel.  The  urethra  is  intact,  although  surrounded  closely  by 
the  tumor  which  has  invaded  the  entire  prostate.  A  fairly  thick  intact 
capsule  surrounds  the  prostate  everywhere  except  at  its  upper  end,  where 
the  growth  has  spread  upward  around  the  lower  ends  of  the  vasa  defer- 
entia  and  seminal  vesicles  and  invaded  the  posterior  surface  of  the 
anterior  part  of  the  trigone.  A  cross  section  through  the  tip  of  the  semi- 
nal vesicles  and  the  trigone  presents  the  following  picture.  Above,  the 
darkly  stained  mucosa  of  the  trigone  apparently  intact,  immediately  be- 
neath this  a  mass  of  carcinoma,  2  cm.  wide,  adherent  to  and  involving 


Fig.  11. — Anterior  view,  showing  trigone,  urethral  orifice,  the  vasa  and 
prostate. 

the  seminal  vesicles  beneath.  Sections  of  the  upper  portion  of  both 
seminal  vesicles  examined  microscopically  are  found  free  from  disease, 
but  the  vas  deferens  is  involved  fairly  high  up  on  each  side,  the  lumen 
being  completely  filled  with  cancer  cells.  The  bladder  wall,  near  the 
upper  line  of  excision,  is  apparently  free  from  invasion,  but  in  the  fat 
beneath  it  and  to  the  outer  side  of  the  seminal  vesicle  small  masses  of 
cancer  cells  are  seen.  The  capsule  covering  the  prostate  and  seminal 
vesicles  is  invaded  on  the  inner  side  in  places.  The  structure  of  the 
neoplasm  is  adenocarcinoma;   in  places  carcinoma  solidum. 

Microscopic  examination. — The  predominating  type  is  that  of  an  adeno- 
carcinoma although  occasional  areas  of  scirrhus  are  encountered.     There 


516  Hugh  H.  Young. 

seems  to  be  quite  a  marked  tendency  of  the  carcinoma  to  arrange  itself 
in  large  tubules.  The  lumina  of  these  tubules  are  filled  with  epithelium 
arranged  in  atypical  acini.  There  is  practically  no  stroma  between  the 
various  epithelial  strands.  There  are  at  times  a  number  of  these  carcin- 
omatous tubules  closely  set  together  separated  by  comparatively  thin  bands 
of  stroma.  On  superficial  examination  these  tubules  often  seem  like  pure 
carcinoma  solidum,  but  on  closer  examination  one  finds  nearly  always 
a  marked  tendency  to  formation  of  acini.  Occasionally,  however,  alveoli 
are  seen  which  are  composed  entirely  of  epithelial  cells  without  any 
disposition  to  assume  glandular  form.  Not  infrequently  irregular  masses 
of  epithelial  cells  are  found  infiltrating  the  stroma.  At  other  times 
these  infiltrations  are  assuming  an  adenomatous  type.  The  carcinoma 
extends  up  along  the  vesicles  showing  the  greatest  tendency  to  involve 
the  vas,  and  at  times  masses  of  carcinoma  are  found  in  the  alveolar  tissue 
outside.  Sections  from  near  the  top  of  the  seminal  vesicles  and  including 
the  vas  at  this  level  show  the  vesicles  free  from  infiltration,  but  the  wall 
of  the  vas  and  the  immediately  surrounding  areola  tissue  is  involved. 
This  extension  of  the  disease  involving  the  vas  preserves  well  an  adeno- 
carcinoma type.  The  epithelium  forming  the  acini  is  mostly  of  a  low 
cylindrical  variety.  In  the  infiltrating  areas  the  epithelial  cells  are 
often  small  and  round  but  may  be  of  various  sizes  and  shapes.  The  nuclei 
vary  much  in  size  and  in  their  staining  properties. 

Convalescence. — Patient  reacted  well  from  the  operation. 

February  20.— Patient  up  in  bed  to-day.     Slight  nausea.     Appetite  fair. 

February  22. — There  has  been  a  good  deal  of  nausea  and  vomiting. 
Pulse  100  to  110.  Perineal  gauze  drainage  partly  removed,  most  of  urine 
coming  through  the  perineum. 

February  23. — Nausea  and  vomiting  marked  to-day.  Temperature  102.5°. 
Saline  infusion  and  salt  solution  by  rectum.  There  is  a  large  pressure 
slough  across  the  small  of  the  back,  due  to  prolonged  pressure  against  a 
hard  sand  bag  at  the  operation. 

February  25. — Condition  improved;  no  nausea;  up  in  a  chair  for  two 
hours. 

March  2. — General  condition  good.  A  portion  of  the  urine  now  passes 
through  his  penis. 

March  9. — Walking  to-day  for  the  first  time.  Wound  doing  well.  Con- 
dition excellent. 

March  IJf. — Temperature  arose  to  102.6°  yesterday;  no  special  symptoms. 

March  17.— On  March  15,  temperature  103°;  on  the  16th,  102.5°;  to-day, 
102.2°.  Patient  has  had  no  pain.  Examination  of  kidneys  is  negative;  no 
tenderness  in  region  of  bladder.  The  wound  looks  well;  urine  is  escap- 
ing freely  through  the  perineum.  To-day  three  silk  worm  gut  sutures 
were  removed;  three  remain.  No  evidence  of  calcareous  deposit  along 
sutures  (in  marked  contrast  to  Case  VII,  in  which  the  sutures  were 
coated  with  lime  salts). 

March  22. — Large  superficial  skin  slough  on  the  back  is  causing  patient 


An  OperatiGn  for  Cancer  of  Prostate.  517 

considerable  trouble.  Large  piece  cut  away  with  scissors  to-day.  Patient 
still  has  some  rise  of  temperature  but  is  up  and  about. 

April  9. — Patient  up  each.  day.  Feels  weak  but  is  gaining  strength. 
Temperature  up  and  down  each  day.  Urine  passed  through  penis  in  large 
quantities  the  first  time  yesterday.     AVound  on  back  much  improved. 

May  n. — Back  healing  slowly.  Perineal  wound  closed.  When  patient 
lies  on  his  back  there  is  no  leakage  or  dribbling  of  urine  from  his  penis, 
but  when  he  is  on  his  feet  he  has  no  control  of  it.  During  the  night 
patient  holds  urine  for  several  hours,  voiding  450  cm.  in  the  morning. 
Urinalysis  1250  cc.  Cloudy,  pale,  acid;  sp.  gr.  1010;  albumin  present  in 
a  small  amount.  Pus  cells  and  bacteria  numerous.  Urea  12  grams  to 
the  litre. 

May  30. — Patient  has  gained  eight  pounds  since  operation,  feels  well, 
can  walk  long  distances.  There  is  no  pain  in  the  region  of  the  perineum, 
of  bladder,  or  in  hips  (all  of  which  were  in  constant  pain  before  opera- 
tion). Does  not  wet  the  bed  at  night.  Holds  urine  for  three  to  four 
hours,  then  gets  up  and  voids  it.  During  the  day  time  has  no  control. 
Has  had  no  erections  since  operation. 

Examination. — Condition  excellent.  Wound  completely  healed.  Rectal 
mucosa  soft;  no  evidence  of  recurrence  in  region  of  wound  or  above.  No 
glands  to  be  felt. 

June  24,  1905. — Patient  says  he  feels  very  well.  Voids  urine  about  every 
two  hours  night  and  day.  When  the  desire  to  urinate  comes  on  he  has  to 
attend  to  it  at  once  or  it  will  escape.  Does  not  wet  the  bed  at  night. 
Wound  healed  tight.  Rectal  mucosa  soft;  no  glands  to  be  felt  in  pelvis. 
Slight  induration  in  region  of  operation,  a  little  more  marked  on  the  left 
side.  No  definite  evidence  of  recurrence.  Urine  pale  yellow  color,  fairly 
clear,  heavy  ring  of  albumin  is  present,  one  hyaline  cast  is  seen. 

March  12,  1906. — Letter.  "  After  leaving  the  hospital  1  was  very  com- 
fortable and  gained  20  pounds  in  weight.  About  September  5,  an  abscess 
formed  in  the  region  of  the  operative  scar,  this  was  followed  by  a  small 
fistula  through  which  a  portion  of  the  urine  escaped,  the  rest  passing 
through  the  natural  channel  into  the  rubber  urinal  which  1  have  never 
ceased  to  wear  when  up  and  about.  On  January  1,  1906,  I  had  an  operation 
performed  to  close  the  fistula.  The  wound  closed  readily  and  I  was 
discharged  January  19.  The  fistula  has  not  reopened.  I  have  no  control 
over  my  urine.  1  now  weigh  167  pounds,  23  pounds  more  than  when  I 
left  the  hospital.     My  appetite  and  digestion  are  very  good." 

Case  X. — Carcinoma  of  prostate.  Complete  excision  of  prostate,  seminal 
vesicles,  ampullce  of  vasa  deferentia,  cuff  of  bladder,  and  one  enlarged  gland. 
Recovery.     Closure  of  perineal  fistula  in  four  weeks.     Well  one  year  later. 

J.  E.  D.,  aged  64,  admitted  May  12,  1905.     No.  930. 

Onset  of  symptoms  about  one  year  ago  with  some  straining  on  urina- 
tion. Voided  urine  about  every  two  hours  during  the  day,  but  only  once 
at  night.     After  a  few  weeks  the  urinary  symptoms  disappeared  and  he 


518  Hugh  H.  Young. 

was  comfortable  until  seven  months  ago.  Urination  then  became  difficult, 
stream  small,  and  urination  frequent  during  the  daj%  but  he  only  had 
to  get  up  once  at  night.  A  catheter  was  passed  and  sixteen  ounces  of 
residual  urine  were  found,  and  after  that  he  was  catheterized  once  a  day 
for  a  month  and  was  treated  by  prostatic  massage  without  benefit.  Two 
months  ago  he  began  to  use  the  catheter  himself  and  has  continued  to 
use  it  two  or  three  times  a  day  until  the  present  time.  In  the  evening 
the  residual  urine  was  about  12  ounces,  but  in  the  morning  he  was  able 
to  void  more  freely  and  finds  only  about  six  ounces  of  residual  urine 
present.  Patient  has  had  no  pain  in  the  region  of  the  bladder,  rectum, 
back,  or  legs.  Has  not  lost  weight  and  is  heavier  than  he  has  ever  been. 
He  has  satisfactory  sexual  intercourse  several  times  a  week.  Ejaculations 
not  quite  so  free  as  formerly.     Has  not  had  hematuria. 

Examination. — Patient  a  healthy  looking  man.  Lips  and  mucous  mem- 
branes of  good  color.  Chest  and  abdomen  negative.  No  enlarged  glands 
to  be  felt. 

Rectal  examination. — The  prostate  is  considerably  enlarged.  The  left 
lateral  lobe  is  much  larger  than  the  right,  bulges  much  farther  toward 
the  rectum,  has  a  very  sharp  lateral  border,  and  extends  farther  upward 
into  the  region  of  the  seminal  vesicle.  The  upper  limits  of  this  lobe  are 
difficult  to  make  out  distinctly,  owing  to  the  fact  that  several  indurated 
cords  run  upward  and  outward  from  the  upper  end  of  the  prostate  appar- 
ently between  the  seminal  vesicles  and  the  rectum.  No  glands  are  to  be 
felt  in  this  region.  The  left  seminal  vesicle  cannot  be  distinctly  made 
out,  but  there  is  definite  induration  in  this  region.  The  consistence  of 
the  left  lateral  lobe  is  much  harder  than  that  of  the  right.  Surface 
smooth,  contour  rounded,  consistence  everywhere  equal  and  no  nodules 
are  present.  It  is  extremely  tender  on  pressure,  especially  near  the  apex, 
where  it  is  quite  prominent.  The  induration  is  not  of  stony  hardness,  but 
is  much  harder  than  that  of  the  ordinary  prostate.  The  right  lateral  lobe 
is  moderatelj'  hypertrophied,  oval  in  shape,  smooth,  elastic,  not  tender, 
and  not  nearly  so  indurated  as  the  left  lobe.  Upper  end  well  limited;  no 
extension  in  the  region  of  the  left  seminal  vesicle,  which  is  soft.  The 
bladder  above  is  soft;  no  glands  are  to  be  felt;  no  intervesicular  mass 
present. 

Careful  examination  of  the  lateral  walls  of  the  pelvis  and  the  sacral 
fossa  failed  to  reveal  any  enlarged  glands. 

Cystoscopic  examination. — Catheter  passed  with  ease.  Residual  urine 
■varies  from  100  cc.  to  400  cc.  Cystoscope  enters  easily,  is  not  distinctly 
grasped  in  the  prostatic  urethra  as  in  some  cases.  Study  of  the  prostatic 
orifice  shows  an  enlargement  of  the  median  portion  in  the  shape  of  a 
small  sessile  lobe.  The  lateral  lobes  are  very  little  enlarged  and  the 
cleft  between  them  is  shallow.  Between  the  lateral  lobes  and  the 
median  enlargement  there  is  a  shallow  cleft  on  each  side.  The  surface 
of  the  prostate  is  smooth  and  the  mucous  membrane  normal  in  appear- 
ance.    Both  ureteral  orifices  are  easily  seen  and  are  normal   in  appear- 


An  Operation  for  Cancer  of  Prostate.  519 

ance.  TTiere"  is  a  slight  pouch,  behind  the  median  enlargement. 
The  bladder  wall  is  considerably  trabeculated  with  numerous  pouches  and 
one  or  two  cellules  between.  There  is  no  neoplastic  growth  to  be  seen. 
Mucous  membrane  is  smooth,  red,  moderately  inflamed.  With  the  finger 
.in  the  rectum  and  cystoscope  in  the  urethra  the  beak  can  easily  be  felt. 
There  is  no  marked  induration  or  increased  thickness  in  this  region,  but 
the  median  portion  of  the  prostate  is  considerably  thicker  than  normal 
and,  by  turning  the  beak  to  the  right  side  of  the  trigone,  palpation  shows 
a  distinct  increase  in  thickness  in  the  region  of  the  left  seminal  vesicle. 
Prostatic  secretion,  obtained  by  massage,  is  composed  almost  entirely  of 
spermatozoa,  some  of  which  are  actively  motile,  a  few  lecithin  cells,  very 
few  granule  cells,  and  some  epithelial  cells. 

Remarks.— The  diagnosis  of  carcinoma  of  the  prostate  is  made  on  the 
induration,  preponderance  of  size,  and  great  tenderness  of  the  left  lateral 
lobe,  its  extension  into  the  region  of  the  seminal  vesicle,  and  the  absence 
of  marked  intravesical  enlargement  around  the  prostatic  orifice. 

May  16.  Operation. — Radical  excision  of  entire  prostate,  seminal  ves- 
icles, ampullae  of  the  vasa  deferentia,  circular  cuff  of  the  bladder,  includ- 
ing the  trigone  to  within  1.5  cm.  of  the  ureteral  orifice.  Anastomosis  of 
anterior  wall  of  bladder  to  the  stump  of  the  membranous  urethra.  Re- 
tained catheter  in  penis.     Partial  closure  of  skin  wound  on  each  side. 

After  introduction  of  the  tractor  through  the  membranous  urethra  the 
rectum  was  found  to  be  more  closely  adherent  to  the  capsule  of  the  pros- 
tate than  usual,  and  had  to  be  dissected  away,  leaving  instead  of  a  smooth 
shining  prostatic  capsule,  as  usually  seen,  a  rough  hemorrhagic  one.  Pal- 
pation of  the  prostate  showed  that  it  was  very  much  harder  than  in  true 
hypertrophy,  and  on  the  posterior  part  of  the  right  lateral  lobe  near  its 
external  border,  a  hard,  sharp,  irregular  ridge  was  felt.  The  diagnosis  of 
carcinoma  was  confirmed  without  cutting  into  it  and  a  radical  operation 
carried  out  with  very  little  difficulty.  Ureters  not  injured.  Bladder  wound 
successfully  closed  with  silk  worm  gut  sutures.  Entire  time  of  opera- 
tion, including  complete  closure  two  hours  and  fifteen  minutes.  Just 
before  closure  one  enlarged  gland  was  found  adjacent  to  left  seminal 
vesicle  and  removed.     Submammary  infusion  during  the  operation. 

Pathological  examination. — The  prostate,  with  its  capsule  and  urethra, 
both  seminal  vesicles,  vasa  deferentia  for  a  distance  of  31/4  cm.,  a  cuff  of 
the  bladder,  which  is  2  cm.  wide  in  the  region  of  the  trigone,  have  been 
removed  in  one  piece.  The  excised  bladder  is  lined  by  normal  looking 
mucous  membrane  and  shows  no  evidence  of  malignancy.  The  prostatic 
orifice  shows  a  small  round  middle  lobe,  and  a  slight  enlargement  of  each 
lateral  lobe,  each  covered  by  smooth  mucous  membrane.  The  capsule  of 
the  prostate  is  rough,  particularly  on  the  anterior  and  posterior  surfaces, 
where  small  adherent  bits  of  tissue  are  seen.  It  measures  5  cm.  wide,  4 
cm.  long,  and  5  cm.  thick.  It  is  hard  in  consistence,  but  no  nodules  nor 
glands  are  to  be  felt.  The  cut  surface  of  the  prostate  is  generally  yellow- 
ish in  color  with  small,  granular,  yellowish  areas  separated  by  a  fine 
Vol.  XIV.— 35. 


580  Hugh  H.  Young. 

stroma  of  lighter  color.  The  capsule  of  the  prostate  is  apparently  not 
invaded  and  the  urethra  is  also  free  from  disease.  Section  of  the  middle 
lobe  shows  the  same  picture  as  described  above.  The  urethra  is  intact 
and  free  from  disease.  The  vasa  deferentia  are  normal  in  size,  smooth, 
not  nodular,  but  feel  quite  firm.  The  left  seminal  vesicle  is  closely  bound 
to  the  upper  end  of  the  prostate.  It  measures  1.5  x  2  cm.  in  size,  and  has 
the  appearance  of  a  benign  atrophied  vesicle.  Both  seminal  vesicles  are 
surrounded  by  a  fatty  areolar  tissue,  but  there  is  no  evidence  of  carcinoma 
in  it.  The  right  seminal  vesicle  is  about  the  same  size  as  the  left,  is  soft 
in  feel,  and  shows  no  evidence  of  involvement.  There  is  no  tumor  mass 
between  the  seminal  vesicles  and  the  bladder. 

Microscopic  study  from  sections  of  both  lateral  lobes  shows  adenocar- 
cinoma which  has  entirely  replaced  normal  structures.  Sections  of  the 
seminal  vesicles  show  that  both  are  invaded  by  carcinoma  near  the 
prostate,  but  are  free  from  disease  higher  up.  The  vasa  deferentia  are 
both  filled  with  cancer  cells  near  the  prostate,  but  sections  taken  at  a  point 
1  cm.  below  the  upper  limit  of  excision  are  normal.  A  longitudinal  section 
through  the  trigone  and  middle  lobe  of  the  prostate  shows  no  involvement 
of  the  trigone.  The  apex  and  posterior  portion  of  the  middle  lobe  is 
composed  of  muscle  and  fibrous  tissue  and  is  not  involved.  Along  its 
anterior  surface  and  beneath  the  urethra  several  masses  of  cancer  cells 
are  seen.  The  capsule  of  the  prostate  and  the  areolar  tissue  around  the 
seminal  vesicles  show  no  invasion. 

Convalescence. — Patient  reacted  well.  Highest  temperature  100.2°P., 
reached  on  second  day.  No  leakage  from  perineal  wound.  Urethral 
catheter  removed  on  seventh  day,  after  which  all  urine  passed  through 
the  penis  for  two  days. 

May  26. — Most  of  urine  is  passing  through  perineal  wound  but  without 
pain.  Temperature  normal.  General  condition  excellent.  Sutured  skin 
wound  healed  per  primam.     Patient  up  in  chair. 

June  9. — Several  silk  worm  gut  sutures  removed  for  the  first  time  to-day. 

June  15. — Nearly  all  the  urine  passes  through  the  penis  but  without 
control.     Rubber  urinal  ordered.     General  condition  excellent. 

June  22. — No  leakage  through  perineum  but  has  no  control  of  urine 
through  penis.     Two  silk  worm  gut  sutures  remain. 

June  27. — Patient  discharged.  General  condition  is  excellent.  Suffers 
no  pain.  Urine  passes  entirely  through  his  penis.  Perineal  wound  healed 
tight  with  the  exception  of  a  pin-point  opening  at  apex,  where  one  stitch 
remains  which  cannot  be  removed. 

Examination  of  rectum  is  negative.  No  enlarged  glands  to  be  felt;  no 
evidence  of  carcinoma  in  region  of  wound.  Rectal  mucosa  soft.  Glands 
of  groin  not  enlarged.     General  condition  of  patient  excellent. 

The  microscopic  character  of  the  carcinoma  varies  in  different  areas, 
in  one  portion  atypical  acini  still  persisting,  while  in  other  areas  there  is 
assumed  carcinoma  simplex.  The  growth  as  a  whole  is  a  very  cellular 
one,   the   epithelium   varying   in   size   and   shape   as   also   do   the   nuclei. 


An  Operation  for  Cancer  of  Prostate.  521 

Oftentimes  the  carcinoma  is  arranged  in  large  alveoli  in  which  the  cells 
are  compact  with  formation  here  and  there  of  small  open  spaces.  The 
epithelium  shows  a  marked  tendency  to  infiltrate  the  stroma,  and  infiltrat- 
ing strands  and  nests  of  epithelium  can  be  seen  in  numerous  areas.  Sec- 
tions taken  from  the  vesical  end  of  the  lateral  lobes  show  a  complete 
replacement  of  the  normal  tissue  by  cancer,  but  the  carcinoma  has  not 
broken  through  the  upper  end  of  the  capsule  to  involve  the  urethral  orifice, 
but  has  apparently  broken  through  at  the  junction  of  the  vesicles  and  vas 
with  the  prostate. 

Diagnosis. — Adenoma  carcinoma  and  carcinoma  simplex,  the  latter  pre- 
dominating. 

May  5,  1906. — Letter.  "  I  am  in  good  health  and  weigh  196  pounds.  The 
incontinence  is  the  same  as  when  in  Baltimore.  The  urine  is  light 
colored  and  copious  in  amount.  I  may  say  that  I  am  in  exactly  the  same 
condition  as  when  last  seen  by  you.  I  was  operated  on  one  year  ago  to-day. 
About  two  or  three  weeks  after  it,  my  foot  began  to  swell  and  was  sore 
to  the  touch;  it  has  never  gotten  entirely  well,  but  gives  me  very  little 
trouble." 

III.  A  Clinical  akd  Pathological  Study  of  37  Cases  of  Cancer 
OF  THE  Prostate.* 

Nineteen  of  these  were  patients  at  the  Johns  Hopkins  Hospital, 
service  of  Dr.  Halsted,  whom  I  wish  to  thank  for  the  privilege  of 
reporting  on  them.  Twenty-one  are  from  the  records  of  my  private 
cases.  The  histories  of  these  40  cases  while  occasionally  incomplete 
have  furnished  considerable  material  for  a  clinical  study,  the  tabulated 
results  of  which,  I  will  take  up  successively. 

Age. — The  ages  were  as  follows : 

1     53  years. 

8    between  55  and  59. 

12     "         60     "     64. 

9  "         65     "     69. 

5  "         70     "     74. 

1  75  years. 

1 76  years. 

As  seen  here  57%  are  between  60  and  70  years  of  age  and  95% 
between  55  and  75.  This  is  in  accord  with  the  statistics  of  Julien,^ 
who  says  that  cancer  of  the  prostate  generally  occurs  between  60  and 
70  years  of  age.  In  100  cases  collected  by  Kaufmann,^  all  were  over 
40,  only  eight  under  50,  and  68%  between  50  and  70. 

*  As  stated  in  a  preceding  footnote  (Case  I),  three  cases  will  have  to  be 
excluded,  as  being  cancer  of  the  bladder  probably  not  arising  from  the 
prostate. 


522  Hugh  H.  Young. 

Wolff  ^  found  6  cases  in  the  literature  under  40,  one  29.  Guyon  °  lias 
reported  a  case  aged  34  with  diffuse  prostato-pelvic  carcinosis,  and  one 
of  Billroth's  "  cases  was  only  30  years  of  age.  These  cases  were  re- 
ported many  years  ago,  however,  and  all  recent  statistics  show  that 
carcinoma  of  the  prostate  is  rarely  seen  before  50  years  of  age.  Some 
of  the  supposed  cases  in  early  years  may  have  been  sarcoma,  which 
occurs  in  young  people. 

Onset. — In  26  cases  the  first  symptom  was  frequency  of  urination, 
in  eleven  associated  with  more  or  less  difficulty  of  urination.  In  many 
cases  both  of  these  symptoms  gave  little  trouble  for  some  time,  and 
in  one  case  no  urinary  trouble  developed  at  all.  One  case  began  with 
sudden  retention  of  urine ;  as  a  rule,  however,  this  came  on  much  later, 
and  in  only  six  cases  persisted.  In  4  cases  complete  retention  occurred 
intermittently.  Pain  was  noted  at  onset  in  only  11  cases  and  in  3 
of  these  it  was  only  a  slight  burning  pain  in  bladder  at  or  before  urin- 
ation. It  was  located  three  times  in  the  penis,  twice  in  the  hip  and 
once  in  the  rectum.  The  pain  was  severe  in  only  a  few  cases.  In  one 
the  first  and  only  symptom  was  a  severe  pain  in  the  hip.  Hematuria 
occurred  only  twice  at  onset,  and  in  one  case  it  remained  the  only 
sjrmptom  for  six  months.  This  case,  however,  showed  extensive 
involvement  of  the  bladder. 

These  statistics  of  the  onset  of  disease  are  not  in  accord  with  the 
commonly  accepted  beliefs  which  have  given  pain  and  especially  hemat- 
uria more  prominent  roles. 

LATER  SYMPTOMS. 

Pcdn. — This  was  present  in  27  cases,  not  present  in  8,  not  noted  in 

5.     It  was  noted  as  occurring  in  the   following  regions — often  in 
several  in  the  same  case. 

Bladder   9    (5  slight.) 

Penis   6 

Perineum   4 

Rectum   3 

Leg    3  (sciatic.) 

Thigh 3 

Sacrum  2 

Testicle  3 

Abdomen 2 

Hip 2 

Groin  2 

Knee    1 

Sole  of  foot  1 


An  Operation  for  Cancer  of  Prostate.  523 

The  vesical  pain  was  frequently  only  a  slight  burning  or  irritation 
during  or  immediately  before  or  after  urination,  occasionally  it  was 
severe  and  spasmodic  in  character  and  reflected  to  the  abdomen  or 
the  rectum.  Very  characteristic  is  the  pain  which  begins  in  the  rectum 
and  radiates  down  the  sciatic  nerve,  sometimes  even  to  the  sole  of  the 
foot  (as  in  one  case). 

It  generally  occurred  on  the  side  in  which  the  disease  had  involved 
the  region  of  the  seminal  vesicle.  The  pains  are  generally  of  a  severe 
aching,  exhausting  character  and  only  occasionally  lancinating. 

Hematuria. — In  20  cases  a  specific  note  has  been  made  that  there 
has  never  been  ^ny  hematuria  and  in  12  cases  no  mention  has  been 
made  of  it.  In  only  7  of  the  37  cases,  is  it  stated  to  have  been 
present.  In  four  of  these  it  was  severe  in  character,  and  in  one  of 
these  villous  tumors  of  the  bladder  were  present,  in  the  third  the 
trigone  was  nodular  and  superficially  ulcerated,  and  in  the  fourth  no 
cystoscopy  or  autopsy  were  obtained.  In  the  other  cases  hematuria 
was  an  insignificant  affair,  and  intermittent  in  character  even  in  one 
case  in  which  large  intravesical  tumors  were  present.  Excluding  the 
cases  in  which  vesical  tumors  were  present  hematuria  has  been  a  rare 
symptom  and  of  little  consequence.  It  seems  rather  to  be  suggestive 
of  vesical  tumor  than  simple  cancer  of  the  prostate,  and  is  certainly 
not  so  commonly  present  as  it  has  been  in  many  cases  of  benign 
hypertrophy  of  the  prostate,  in  the  middle  lobe  forms  of  which  it  is 
no  uncommon  symptom. 

Retention  of  Urine. — In  all  cases  but  one  some  residual  urine  was 
present,  in  20  cases  incomplete  retention,  in  7  cases  complete  retention 
requiring  catheter  life;  and  in  6  cases  intermittent  complete  retention. 
In  8  cases  no  note  has  been  made  on  this  point. 

An  early  large  residual  urine  has  been  quite  common,  and  sometimes 
associated  with  little  evidence  of  obstruction.  One  patient  said  that 
he  had  no  difficulty  or  frequency  of  urination,  and  was  surprised  when 
500  ce.  residual  urine  was  found.  Except  when  invaded  by  the  disease, 
the  bladder  was  seldom  contracted,  and  as  a  rule  it  was  found  remark- 
ably healthy  even  when  frequent  catheterism  had  been  necessary.  The 
passage  of  a  catheter  has  frequently  shown  a  contracture  of  the  pros- 
tatic urethra,  a  sensation  of  firm  and  rough  resistance  immediately 
on  entering,  which  was  entirely  different  from  the  obstruction  to  the 
catheter  experienced  in  ordinary  hypertrophies,  in  which  the  instru- 


524:  Hugh  H.  Young. 

nient  generally  traverses  a  considerable  distance  in  the  prostatic 
urethra  before  being  abruptly  stopped  by  the  obstruction  (the  middle 
lobe). 

Clinical  Examinaiion.  Prostate. — The  prostate  has  been  described 
as  considerably  enlarged  in  23  cases,  moderately  enlarged  in  8  cases, 
and  only  slightly  enlarged  in  5  cases.  The  consistence  was  hard  in 
30  cases,  in  places  hard  and  in  others  soft  in  5  cases,  nodular  in  IT 
cases  and  soft  in  no  cases.  ]\Iarked  tenderness  has  only  been  noted 
once  in  the  37  cases.  In  this  case  (Case  X,  completely  reported 
above)  the  left  lobe  of  the  prostate  contained  near  its  apex 
a  prominent  rounded  enlargement  which  was  extremely  tender  on 
pressure.  Other  portions  of  the  prostate  although  shown  later  to  be 
carcinomatous  were  not  tender.  Sixteen  of  the  cases  were  described 
as  nodular.  In  the  great  majorit}^  of  the  cases,  however,  only  a  slight 
irregularity  of  surface  was  present  and  no  marked  nodules.  In  those 
cases  which  were  not  very  far  advanced  in  the  disease  the  prostate  often 
presented  a  smooth  rounded  surface,  but  markedly  indurated.  This 
induration  was  most  often  of  stony  hardness.  At  times  there  was  a 
softer  induration  which  gave  way  somewhat  on  pressure.  The  contrast, 
however,  between  the  induration  in  these  cases  and  the  usual  elasticity 
of  the  ordinary  h^-pertrophied  prostate  was  very  marked. 

Seminal  Vesicles. — It  was  in  the  region  immediately  above  the  pros- 
tate on  each  side  in  which  the  most  significant  changes  were  found, 
and  induration  in  one  or  both  of  the  seminal  vesicles  was  found  in 
29  cases.  In  two  cases  in  which  the  vesicles  were  said  to  be  free 
from  disease,  the  prostatic  carcinoma  presented  into  the  bladder  and 
vesical  tumors  had  developed.  In  one  case  it  was  uncertain  whether 
the  vesicles  were  involved  or  not  and  in  two  cases  no  note  was  made. 
In  a  few  cases  the  involvement  above  the  prostate  was  in  the  shape  of 
a  small  rounded  indurated  mass  at  the  lower  portion  of  the  seminal 
vesicles.  Generally  it  extended  well  up  for  the  entire  distance  of  the 
seminal  vesicle  and  frequently  it  continued  upward  and  outT\'ard  to  the 
pelvic  wall  and  beyond  the  reach  of  the  finger,  but  these  cases  were 
seen  late. 

In  such  cases  the  examination  usually  revealed  a  mass  in  the  shape 
of  a  bundle  of  indurated  cords  with  intervening  deeper  indurated  and 
soft  areas  extending  upward  and  outward  from  the  upper  end  of  the 
prostate  to  which  it  was  closely  adherent.  In  only  three  cases  were 
enlarged  pelvic  glands  noted. 


An  Operation  for  Cancer  of  Prostate.  535 

In  recent  cases,  vrhere  more  careful  notes  have  been  made,  an  indu- 
ration in  the  intervesicular  space  has  been  noted  in  ten  cases.  This 
presented  as  a  flat  hard  plateau  above  the  prostate  in  the  middle  line, 
continuous  with  the  seminal  vesicle  on  one  or  both  sides  and  usually 
presenting  a  sharp  curved  upper  border,  above  which  sometimes  the 
soft  bladder  could  be  felt.  This  intervesicular  mass  of  induration 
which  has  been  shown  microscopically  to  be  composed  of  infiltration  of 
the  tissues  around  the  vasa  deferentia  and  between  them  and  the 
bladder,  is,  I  think,  the  most  positive  clinical  finding  of  carcinoma  of 
the  prostate.  I  know  of  no  other  condition  in  which  it  occurs  and  it 
always  means  that  the  disease  has  travelled  upward  for  a  certain 
distance  at  least  above  the  prostatic  limits. 

In  4  cases  the  rectum  was  pushed  back  and  partiall}'  occluded  by 
the  prostatic  tumor,  but  in  only  two  cases  were  notes  made  that  the 
rectum  was  involved  by  the  growth,  and  in  but  one  of  these  was  it 
ulcerated.  Involvement  of  the  rectal  wall  certainly  occurs  very  late 
in  the  disease,  as  shown  by  these  cases. 

The  Bladder. — The  bladder  was  examined  cystoscopically  in  20 
cases.  In  17  it  was  found  normal  with  the  exception  of  cystitis, 
trabeculation,  and  pouch  formation.  In  three  cases  intravesical  tumors 
were  present,  once  single,  once  double,  all  of  a  villous  type. 
The  single  and  double  tumors  were  in  the  region  of  a  ureteral  orifice. 
In  one  case  the  trigone  was  ulcerated  and  nodular  and  in  another  case 
there  was  a  peculiar  plateau  in  the  anterior  part  of  the  trigone  behind 
the  prostatic  orifice.  Examination.,  of  tbe  bladder  by  suprapubic  cyst- 
otomy showed  no  involvement  in  one  case,  and  a  nodular  elevated 
trigone  in  the  other.  Two  autopsies  showed  the  bladdetr  to  be 
uninvolved. 

The  intravesical  portion  of  the  prostate. — Study  of  prostatic  orifice 
with  the  cystoscope  showed  no  enlargement  in  5  cases.  In  12  cases 
there  was  a  slight  elevation  of  the  median  portion  of  the  prostate  in 
the  shape  of  a  small  bar.  In  3  cases  a  very  small  rounded  median 
lobe  was  present,  and  in  one  case  a  fairly  large  median  lobe.  The 
lateral  lobes  were  intravesically  enlarged  in  only  4  cases  and  in  one 
of  these  it  was  slight.  In  3  cases  the  intravesical  prostatic  out- 
growth was  villous  in  type  and  associated  with  tumors  of  the  bladder 
in  three  cases.      (These  3  cases  are  now  excluded.     See  footnotes.) 

Glandular  Involvement. — Enlarged  glands  have  been  noted  in  onlv 


526  Hugh  H.  Young. 

11  of  the  40  cases  as  follows:  Deep  pelvic  glands  four  times,  inguinal 
five  times,  iliac  twice,  sacral  twice,  axillary  once,  epitrochlear  once. 

In  recent  cases  I  have  made  very  careful  examinations  with  the 
object  of  palpating  if  possible  enlarged  pelvic  glands  (as  these  are  the 
nearest  to  the  seat  of  the  disease)  and  only  twice  have  been  able  to 
detect  them,  although  in  several  cases  extensive  involvement  above  the 
seminal  vesicle  on  one  or  both  sides  was  present.  In  many  of  these 
cases  indurated  lymphatics  could  be  easily  felt  extending  upward  and 
outward,  but  even  on  bimanual  palpation  no  pelvic  or  iliac  glands  could 
be  felt.  In  one  case  a  small  bunch  of  glands  could  be  felt  about  the 
middle  of  the  sacral  fossa,  high  up,  along  the  posterior  wall  of  the 
rectum,  and  in  another  case,  in  which  examination  for  pelvic  glands 
was  negative,  operation  disclosed  a  carcinomatous  gland  at  the  upper 
end  of  the  left  seminal  vesicle.  It  therefore  seems  certain  that  the 
absence  of  palpable  glands  is  of  very  little  prognostic  value. 

This  corresponds  to  the  findings  of  Kaufmann,*  who  discovered 
involvement  of  the  pelvic  glands  in  only  27  out  of  100  autopsies.  In 
one  of  our  cases  in  which  the  tibige,  vertebrae,  and  ribs  contained  num- 
erous metastases,  only  one  metastatic  gland  and  that  a  bronchial  gland 
was  found. 

Loss  of  iveigM  was  considerable  in  18  cases  and  slight  in  3.  Ko 
notes  were  made  on  this  point  in  9  cases  and  it  was  absent  in  7.  In 
several  of  my  cases  in  which  the  carcinoma  had  spread  to  the  region 
of  one  or  both  of  the  seminal  vesicles  the  patient  still  felt  strong  and 
had  lost  nothing  in  weight.  In  several  other  cases  an  early  emaciation 
was  noted.  As  the  disease  progresses  this  symptom  is  unquestionably 
very  characteristic. 

Increase  in  thickness  in  the  suburethral  portion  of  the  prostate. — 
After  cystoscopy,  but  before  withdrawal  of  the  cystoscope,  it  has  been 
my  custom  for  several  years  to  insert  the  index  finger  of  the  right  hand 
into  the  rectum  to  ascertain  the  thickness  of  the  posterior  commissure 
(particularly  the  "median  portion"  beneath  the  vesical  orifice)  and 
the  trigone  and  tissues  beneath.  In  many  cases  of  prostatic  hyper- 
trophy although  a  considerable  increase  in  the  median  portion  of  the 
prostate  is  detected,  it  is 'possible  to  feel  the  beak  in  the  bladder  and 
show  the  absence  of  tumefaction  between  the  trigone  and  the  rectum. 
The  anterior  half  of  the  posterior  commissure  is  usually  found  to  be 
little  thicker  than  normal  and  soft. 

In  these  cases  of  carcinoma  the  findings  have  been  entirely  different. 


An  Operation  for  Cancer  of  Prostate.  527 

the  entire  suburethral  portion  of  the  prostate — the  posterior  commis- 
sure has  been  found  thicker  and  harder  than  normal,  the  prostate 
appearing  as  a  hard  thick  ring  firmly  grasping  the  cystoscope.  It  has 
generally  been  impossible  to  feel  the  beak,  thus  showing  a  tumefaction 
beneath  the  trigone  in  the  intervesicular  space.  By  directing  the  beak 
of  the  cystoscope  far  to  one  side  it  has  been  possible  to  get  a  more 
accurate  idea  of  the  region  of  the  seminal  vesicle,  and  the  extent  of  any 
involvement  which  be  present. 

This  increase  in  thickness  and  hardness  in  the  suburethral  and 
subtrigonal  tissues,  taken  in  conjunction  with  the  presence  of  little  or 
no  intravesical  prostatic  enlargement  has  proved  a  very  important 
diagnostic  finding. 

The  pathology  as  shown  in  8  autopsies  and  8  operations. — "We  have 
not  the  space  to  go  more  than  briefly  into  the  varied  phases  of  car- 
cinoma of  the  prostate.  That  it  may  begin  in  a  benign  adenomatous 
hypertrophy  is  shown  in  Case  No.  9  (in  appendix)  in  which  a  section 
of  the  lobes  removed  at  operation  showed  benign  adenoma. 

A  localized  hard  rounded  mass  in  each  lateral  lobe  surrounded  by 
soft  prostatic  tissue  was  found  in  Case  IV,  and  here  again,  after  a 
Bottini  operation  the  patient  felt  well  for  two  years,  when  extensive 
malignant  disease  of  prostate,  vesicles,  and  bladder  was  discovered. 

In  most  of  the  cases,  however,  there  was  a  marked  induration  often 
of  stony  hardness,  generally  smooth,  sometimes  rough  and  nodular, 
and  involving  both  lobes. 

The  operations  and  autopsies  have  both  shown  a  remarkable  freedom 
of  the  outer  portion  of  the  capsule  of  the  prostate  from  neoplastic 
invasion.  In  sections  which  show  not  a  remnant  of  the  original  glan- 
dular structure  of  the  prostate  left,  the  prostatic  capsule  is  seen  to  be 
intact.  Some  of  the  inner  layers  occasionally  show  small  masses  of 
cancer  cells  in  the  lymph  spaces  and  along  the  course  of  the  nerves 
and  blood-vessels,  but  the  outer  layer  still  uninvaded.  Sometimes  the 
disease  passes  through  the  capsule  and  invades  the  rectum,  but  gener- 
ally very  late.  As  is  well-known  the  posterior  surface  of  the  prostatic 
capsule  is  rendered  much  thicker  and  stronger  by  the  incorporation 
of  the  firm  prostato-peritoneal  aponeurosis  of  Denonvilliers,  which 
covers  intimately  the  posterior  surface  of  the  prostate  and  the  seminal 
vesicles  and  passes  on  upward  beneath  the  posterior  parietal  periton- 
eum. The  base  of  the  prostate  between  the  ejaculatory  ducts  and  the 
bladder,  not  having  the  support  of  this  strong  fascia  is  covered  by  a 
Vol.  XIV.— 36. 


528 


Hugh  H.  Young. 


much  weaker  capsule,  and  it  is  here  that  the  disease  passes  beyond 
the  limits  of  the  gland  proper.  Cross  sections  in  this  region  fre- 
quently show  the  seminal  vesicles  and  vasa  deferentia  filled  with 
cancer  cells,  with  their  outer  fibrous  walls  intact,  showing  con- 
clusively that  the  disease  has  travelled  up  the  ducts.  In  one  case  an 
apparently  healthy  vas  deferens  was  found  to  be  filled  with  carcino- 


"T^'jp"***^^- 


^ 


Fig.  12. —  (Case  13.)     Schirrous  form  of  adeno-carcinoma. 


matous  elements  at  a  point  i  cm.  above  the  prostate.  The  lymphatics, 
and  nerve  sheaths  are  also  common  avenues  for  transmission  of  the 
disease,  and  can  often  be  palpated  by  rectum  as -firm  rounded  cords 
running  upward  and  outward  beneath  the  fascia,  sometimes  completely 
masking  the  seminal  vesicle. 

Several  of  my  specimens  show  beautifully  the  intervesicular  plateau 
of  infiltration,  spoken  of  before.  It  is  found  to  be  composed  micro- 
scopically of  masses  of  cancer  cells  in  and  around  the  vasa  deferentia 


An  Operation  for  Cancer  of  Prostate. 


529 


and  between  them  and  the  base  of  the  bladder..  In  these  cases  the 
outer  layers  of  the  bladder  muscle  are  usually  found  invaded  by  narrow 
prolongations  of  the  disease.  In  several  instances  this  extended  a  very 
short  distance  up  the  trigone,  the  bladder  being  entirely  healthy  before 
the  region  of  the  ureters  was  reached.     The  mucosa  is  rarely  broken 


Fig.  13. —  (Case  64.)  A  medullary  form  of  carcinoma  in  which  there  is 
very  little  stroma  and  the  cancer  cells  varying  in  size  and  shape  are 
loosely  arranged. 


through.  In  three  of  these  cases  the  trigone  was  invaded,  once  ele- 
vated, once  ulcerated,  and  once  the  site  of  a  polypoid 
tumor.  In  those  cases  in  which  the  cystoscope  shows  slight  en- 
largement of  the  prostate  around  the  vesical  orifice,  the  disease,  if  it 
invades  the  bladder  at  all,  attacks  the  trigone,  and  if  an  intravesical 
tumor  appears  it  is  usually  near  one  of  the  ureteral  orifices.     I  have 


530 


Hugh  H.  Young. 


seen  one  such  case  in  which  there  was  a  direct  continuation  of  the 
disease  from  a  carcinomatous  seminal  vesicle  through  the  bladder  wall 
into  a  small  papillary  tumor  at  the  right  ureteral  orifice. 


TN!N.r<i«.d.. 


Fig.  14. —  (Case  10.)  A  tubular  form  of  carcinoma  in  which  solid  strands 
of  epithelial  cells  are  seen  growing  into  the  lumina  of  the  tubules  and 
by  their  union  forming  irregular  open  spaces.  There  is  no  infiltration 
of  the  stroma. 


Microscopically  the  types  of  carcinoma  vary  in  the  prostate  as  they 
do  in  other  organs. 

The  most  common  type  is  a  mixed  adenocarcinoma  and  carcinoma 
simplex,  this  being  the  form  present  in  11  of  the  18  cases  in  which 


An  Operation  for  Cancer  of  Prostate. 


531 


microscopic  examinations  were  made.  Four  of  these  showed  some 
areas  of  pure  adenocarcinoma  while  other  areas  presented  the  scirrhus 
type.  These  might  be  termed  a  scirrhus  variety  of  adenocarcinoma. 
Pig.  12  (Case  13)  is  an  area  of  scirrhus  from  one  of  these  cases. 

In  seven  cases  the  adeno  type  varied  with  portions  in  which  the 
epithelium  formed  islands  of  cells  'separated  from  each  other,  some- 
times by  slender  and  sometimes  by  broad  bands  of  stroma.      Often, 


Fig.  15.— (Case  10.) 
of  muscle. 


Nests  of  cancer  cells  lying  in  between  dense  bundles 


however,  the  carcinoma  is  seen  breaking  through  these  limiting  bands 
of  stroma  and  infiltrating  lawlessly  so  that  the  alveolar  arrangement 
may  be  entirely  lost. 

In  three  cases  the  neoplasm  was  a  carcinoma  simplex;  two  of  the 
medullary  and  one  of  the  scirrhus  type. 

Fig.  13  from  Case  64  represents  the  very  cellular  character  of 
one  of  these  medullary  tumors,  and  the  insignificant  amount  of  stroma 
present.     A  large  portion  of  the  tumor  was  of  this  character.     It  is 


532 


Flugli  II.  Young. 


seldom  that  the  carcinoma  presents  a  j)ure  adenoma  type,  but  it  ex- 
hibits a  marked  tendency  to  infiltrate.     The  acini  may  be  reproduced 


Fig.  16. —  (Case  9.)  A  small  carcinoma  nodule  about  2  mm.  in  diameter 
in  an  otherwise  benign  prostate.  Some  of  the  normal  acini  still  persist 
in  the  cancerous  area. 


in  quite  a  regular  manner,  but  it  -is  seldom  they  simulate  closely  a 
normal  acinus. 


An  Operation  for  Cancer  of  Prostate. 


533 


In  two  cases  the  prostatic  tumor  was  what  might  be  termed  a  tubu- 
lar form  of  adenocarcinoma.  Fig.  14  (Case  10)  represents  an  area 
from  one  of  these  cases.  Sections  from  the  portions  are  very  similar 
in  character  and  present  this  same  peculiar  structure.  Only  very  oc- 
casionally was  any  tendency  to  infiltration  displayed,  although  the 
growth  had  partially  invaded  the  deeper  layers  of  the  capsule. 


Fig.  17. —  (Case  14.)      Shows  an  acinus  partly  lined  by  cancer  cells  and 
partly  by  normal  epithelium.     The  cancer  cells  are  large  and  pale  staining. 


In  one  portion  of  this  tumor  .there  was  present  a  marked  hyper- 
plasia of  the  muscle  in  which  islands  of  cancer  cells  were  irregularly 
distributed.     (See  Fig.  15,  Case  10). 

In  two  cases  the  neoplasm  was  principally  pure  adenocarcinoma. 
In  one  a  small  nodule  of  cancer  about  1  mm,  in  diameter  was  found 
(see  Fig.  16,  Case  9).     About  %  of  the  nodule  is  included  in  this 


534  Hugh  H.  Young. 

drawing,  which  includes  some  of  the  normal  tissue  surrounding  the 
cancerous  area. 

Fig.  17  (Case  14)  is  shown  principally  because  it  contains  an 
acinus  one  portion  of  which  is  invaded  by  cancer  while  the  other  por- 
tion is  lined  by  normal  epithelium. 

Metastases.  Microscopic  examination  of  the  metastatic  growths 
were  made  in  four  cases.  In  one  (Case  13)  the  primary  tumor  was  a 
scirrhous  variety  of  adenocarcinoma,  and  sections  from  the  glands 
showed  pure  adenocarcinoma. 

In  another  (Case  64),  the  original  growth  was  a  cellular  carci- 
noma simplex  (Fig.  13),  while  the  extensive  metastases  were  all  colloid. 
In  a  third  case  the  metastases  and  prostatic  tumor  were  similar,  both 
being  tubular  adenoma. 

In  the  fourth  case  the  glands  were  the  seat  of  a  diffuse  carcino- 
matous invasion,  while  the  original  growth  was  a  mixed  one — adeno- 
carcinoma and  carcinoma  simplex. 

IV.  A  Study  of  the  Cases  in  the  Literature  in  which  Oper- 
ations POR  Carcinoma  of  the  Prostate  v^ere  Performed 
I  find  26  cases  of  primary  carcinoma  of  the  prostate  reported.  To 
these  I  have  added  6  eases  from  my  own  practice  (here  reported). 
I  have  not  included  cases  in  which  the  Bottini  operation  was  employed 
(omitting  thus  6  of  my  own  cases).  The  cases  of  carcinoma  of  the 
rectum  involving  the  prostate  and  of  sarcoma  of  the  prostate  which 
have  been  included  by  Oraison,  Pousson,  and  Hawley  have  no  place 
here,  but  I  have  referred  to  them  briefly  to  show  why  they  should  be 
excluded.  I  have  grouped  these  cases,  according  to  the  operation 
performed  as  follows : 

Partial   Operations.     (Enucleations,   Curettage,   Partial 

Excision.) 

Perineal  route.     12  cases. 

1-2.  Billroth.'"'  1867.  2  cases.  1,  aged  30.  Lateral  perineal  in- 
cision "  removal  of  very  soft  tumor  size  of  a  duck's  egg."  Eecurrence 
two  months.  Death  14  months.  2,  aged  56.  Irregular  middle  lobe. 
Median  perineal  incision.  Curettage  of  middle  lobe.  Death  4  days. 
Peritonitis. 

3.  Harrison."^  1882.  1  case,  aged  64.  Median  perineal  enucle- 
ation, small  middle  lobe.     Eecurrence.     Death  14  months. 


An  Operation  for  Cancer  of  Prostate.  ■     535 

4.  Heath."  1887.  Perineal  route,  partial  excision.  Death  30 
days. 

5.  Adenot."  1901.  1  case,  aged  56.  Perineal  enucleation  of  pros- 
tate, urethra  and  capsule  not  excised.     Recurrence. 

6.  Greene."'  1903.  1  case,  aged  59.  Enucleation  of  prostatic 
lobes.     Eecover}^  from  operation  not  followed, 

7-10.  Pousson.'  1904.  Albarran's  operation.  Enucleation  of 
prostatic  lobes,  leaving  capsule  and  urethra  in  all  4  cases. 

Results. — 

Case.  I,  57  years,  followed  three  months,  apparently  well. 

Case  II,  54  years  (also  curettement  of  neck  and  bladder).  Recur- 
rence and  death  5  months. 

Case  III,  62  years,  nine  months  later  patient  apparently  well. 

Case  IV,  66  years,  recurrence  and  death  9  months  later. 

11.  Young,  1903.  (Case  VI.)  Patient  aged  75.  Duration  3 
years.  Pain  18  months.  Hard  prostate.  Diagnosis :  Benign  sclerotic 
hypertrophy.  Perineal  enucleation.  Recurrence.  Urinary  obstruction. 
Bottini  operation.    Partial  relief.    Death  one  year  later.    ITo  autopsy. 

Suprapubic  route.     9  cases. 

1.  Belfield."  1888.  1  case,  aged  48.  Villous  outgrowth  from  left 
lateral  lobe  removed  by  forceps,  curette  and  cautery.  Recurrence  2 
months.     Death  5  months. 

2.  Czerny.  (Stein.")  1889.  1  case,  aged  42.  Partial  removal 
with  curette  and  cautery.     Not  followed. 

3.  Parona.""*  1891.  1  case.  Excision  middle  lobe.  Recurrence 
and  death  later. 

4-5.  von  Frisch."  1898.  2  cases.  Excision  of  middle  lobe, 
*■  fully  cured  and  well  one  year  after  operation." 

6-7.  Harrison.^"  1903.  2  cases.  1,  aged  64.  "  Piecemeal  excis- 
ion." Recurrence.  Death  4  months.  2,  aged  61.  Recurrence  16 
months  later. 

8,  Jacobson.^  1901.  1  case,  aged  61.  Frequency  of  urination  and 
intermittent  hematuria  one  year.  Prostate  large,  hard,  and  nodular, 
adherent  to  rectum.  Operation. — Suprapubic  prostatectomy.  Enu- 
cleation of  lateral  lobes.  Result. — Ulceration  into  the  rectum.  Death 
at  the  end  of  six  months  from  recurrence. 

9.  Young.  1901.  (Case  II.)  1  case,  aged  67.  Indurated  pros- 
tate, large  vesical  calculus.  Suprapubic  prostatectomy.  Three  and  a 
half  years  later  extensive  retroperitoneal  metastases. 

Vol.  XIV.— 37. 


536  Hugh  H.  Young. 

Eadical  Operatioxs.     (Peostate,  Capsule,  and  Ueethra  at 
Least  Eemoved.) 

A.  Complete  excision  of  Prostate,  the  entire  bladder  and  the  seminal 
vesicles.     Transplantation  of  ureters  into  rectum.     1  case. 

Kiister.^  1891.  1  case,  aged  53.  Pain,  difficulty  in  micturi- 
tion, hematuria.  Prostate  hard,  irregular,  continuous  above  with 
indurated  seminal  vesicles  and  bladder.  Cystoscope  showed  a  tumor 
of  the  posterior  wall  of  the  bladder. 

Operation :  Suprapubic  incision,  enucleation  of  entire  bladder.  Per- 
ineal incision,  division  of  membranous  urethra,  separation  of  prostate 
and  seminal  vesicles  from  surrounding  structures.  Division  of  ure- 
ters just  above  bladder.  Eemoval  of  bladder,  vesicles,  and  prostate  in 
one  piece.  Transplantation  of  ureters  into  rectum.  Death  five  days 
later. 

B.  Complete  excision  of  Prostate,  most  of  the  Madder,  prodahly  the 
seminal  vesicles.     Transplantation  of  ureters.     1  case. 

Harris.^  1902.  One  case,  aged  53.  Hematuria  and  frequency  of 
urination  for  one  year.  Prostate  hard  and  irregular,  tender.  ISTo 
note  on  seminal  vesicles.  Cystoscope  showed  a  vesical  tumor  involv- 
ing the  trigone  and  base  of  bladder. 

Diagnosis :  Carcinoma  of  bladder  extending  into  and  involving  the 
prostate. 

Operation:  Suprapubic  incision.  Transverse  division  of  urethra  in 
front  of  prostate.  Eemoval  of  entire  prostate,  and  all  but  the  vertex 
of  the  bladder  7  cm.  in  diameter.  Transplantation  of  ureters  into 
the  remaining  portion  of  bladder.  ISTo  attempt  to  suture  the  bladder 
to  membranous  urethra.  Eecovery.  Death  two  months  later  from 
pneumonia.  At  that  time  patient  was  wearing  a  catheter  in  penis 
through  which  most  of  the  urine  escaped.     Suprapubic  fistula  present. 

Autopsy:  Pneumonia,  right  lung.  Eight  kidney  small,  interstitial 
nephritis.  Left  kidney  normal.  Ureters  patent.  Extensive  new  for- 
mation of  bladder  epithelium  around  catheter  reaching  almost  to 
membranous  urethra.  Metastases  in  glands  near  aorta  and  kidney. 
Examination  of  specimen  shows  carcinoma  of  prostate  and  base  of 
bladder. 

C.  Complete  excision  of  Prostate,  the  seminal  vesicles  and  adjacent 
portion  of  Bladder,  leaving  ureters  intact.     4.  cases. 

Young.     1904.     (Cases  AHI-X  reported  in  full  above.)     4  cases. 


An  Operation  for  Cancer  of  Prostate.  537 

Perineal  operation.  Exposure  of  membranous  urethra,  incision,  inser- 
tion of  prostatic  "  tractor,"  transverse  section  of  membranous  urethra, 
separation  of  prostate  and  vesicles  from  surrounding  structures.  In- 
cision of  anterior  wall  of  bladder  1  cm.  above  prostate,  excision  of 
cuff  of  bladder  with  prostate  (division  of  trigone  close  to  ureters). 
Division  of  vasa  deferentia,  removal  of  prostate,  cuff  of  bladder, 
vesicles  and  vasa  in  one  piece.  Eestoration  of  defect  by  anastomosis 
of  anterior  wall  of  bladder  with  membranous  urethra,  closure  of  re- 
mainder of  bladder  opening.  Eetained  catheter  in  urethra.  Partial 
closure. of  perineal  wound. 

Case  I. — No.  15,929,  aged  70  years.  Duration,  one  year.  Bottini  opera- 
ation  (elsewhere)  three  months  ago.  Prostate  large,  hard,  seminal  ves- 
icles involved.  Recovery.  Restoration  of  urination  through  urethra.  Sub- 
sequent formation  of  vesical  calculi,  litholapaxy  nine  months  after  first 
operation.     Death,  sepsis.     Recurrence  found  at  autopsy. 

Case  II. — No.  16,675,  aged  64  years.  Duration,  three  years.  Prostate 
hard,  large,  trigone  involved  by  neoplasm,  no  ulceration.  Both  urethral 
papillEe  excised  with  trigone  at  operation.  Recovery.  Death  six  weeks 
after  operation  from  renal  complications.   Autopsy:    No  carcinoma  present. 

Case  III. — Of.  No.  829,  aged  65  years.  Duration  of  symptoms,  four 
years.  Lower  portion  of  vesicles  and  trigone  invaded.  Excision  com- 
plete. Closure  good.  Recovery.  Restoration  of  urination  through  urethra, 
closure  of  fistula.     Well  thirteen  months  after  operation. 

Case  IV. — Of.  No.  930,  aged  64  years.  Duration  of  symptoms,  one  year. 
Prostate  large,  tender,  hard  left  lateral  lobe,  seminal  vesicle  and  lymph- 
atic gland  involved,  right  lobe  and  vesicle  soft.  Trigone  involved  near 
prostate.  Excision  complete,  with  one  involved  pelvic  gland.  Closure 
satisfactory.  Recovery.  Perineal  wound  closed.  Discharged  five  weeks 
later  apparently  well. 

D.    Excision    of   Prostate    without   Seminal   vesicles.     S    cases. 

1.  Leisrink.""  1882.  1  case,  aged  64,  who  had  suffered  with  a 
dull  aching  pain  in  the  rectum  for  18  months.  No  pain  or  difficulty 
of  urination.  Prostate  enlarged,  indurated  in  region  of  both  seminal 
vesicles. 

Operation :  Exposure  of  prostate  through  perineum.  Excision  of 
prostate  with  capsule  from  bladder  and  membranous  urethra.  Sem- 
inal vesicles  not  removed.  Suture  of  anterior  wall  of  bladder  to  mem- 
branous urethra.     Death  13  days  after  the  operation. 

Autopsy  showed  complete  removal  of  carcinomatous  tissue — no 
glands  involved. 


538  Hugh  H.  Young. 

2.  Czerny.  1889.  (Stein.")  1  case,  aged  47  years.  Urinary 
obstruction  2  years.  Pain  in  rectum  nine  months.  Prostate  hard 
and  large. 

Operation:  Suprapubic  cystostomy.  Discovery  of  a  large  tumor  of 
the  left  lobe,  ulcerated  and  projecting  into  the  bladder.  Lithotomy 
position.  Perineal  excision  of  entire  prostate.  Seminal  vesicles  and 
floor  of  bladder  not  removed.  Eeunion  of  bladder  with  urethra  im- 
possible. Operative  recovery.  Perineal  fistula.  Death  nine  months 
later.     No  autopsy. 

3.  Fuller.^  1898.  1  case,  aged  69.  Frequency  and  difficulty  of 
urination;    hematuria.     Prostate    enlarged,    firm,    smooth,    regular. 

Diagnosis:  Simple  hypertrophy. 

Operation:  Suprapubic  cystostomy.  Discovery  of  intra-vesical 
tumor  of  prostate  involving  the  adjacent  anterior  wall  of  bladder. 
Division  of  membranous  urethra.  Excision  of  prostate  with  small 
portion  of  anterior  vesical  wall.  Seminal  vesicles  and  trigone  not 
removed.  Suture  impossible.  Operative  recovery.  Eestoration  of 
normal  urination.     Death  11  months  later  from  recurrence. 

E.  Rectum  and  Prostate  involved  hy  Cancer.     5  cases. 
Demarquay."*     1873.     Two  cases  of  carcinoma  of  rectum  involv- 
ing the  prostate. 

I.  Aged  — .  Excision  through  anus  and  rectum  of  anterior  wall  of 
rectum  and  adjacent  indurated  portions  of  prostate,  "urethra  and 
ejaculatory  ducts  respected."     Eecovery.     Well  at  end  of  two  years. 

II.  Aged  53.  Excision  through  anus  of  anterior  wall  of  rectum, 
the  prostate,  seminal  vesicles  and  portion  of  trigone.  Ko  attempt  to 
close  bladder  and  rectum.     Death  8  days  later. 

III-IA".  Depage.^  Two  cases.  1.  Carcinoma  of  rectum  involving 
prostate.  Partial  excision  of  prostate  with  wall  of  rectum.  Second 
operation  to  close  recto-vesical  fistula  successful.  Ultimate  result 
not  given.  2.  Excision  through  rectum  of  a  prostatic  carcinoma,  size 
of  an  apple  which  involved  rectum.     Death  in  9  days. 

V.  Czerny.  (Stein.")  1889.  1  case,  aged  65.  Cancer  of  pros- 
tate involving  rectum  and  seminal  vesicles.  Excision  through  per- 
ineum of  prostate,  portion  of  bladder,  seminal  vesicles  and  a  portion  of 
the  anterior  wall  of  rectum.  Suture  of  bladder  to  membranous  ure- 
thra with  three  sutures.     Death  12  days  after  operation. 


An  Operation  for  Cancer  of  Prostate.  539 

F.  Sarcoma  of  Prostate.     3  cases. 

I.  Spanton,'^  1882.  1  case,  aged  70.  Constant  pain  in  rectum. 
No  urinary  trouble.  Prostate  size  of  a  foetal  head.  Partial  removal 
through  perineum.     Death  on  following  day. 

II.  Socin.  (Burckhardt."")  1894.  1  case,  aged  50.  Constipation. 
No  urinary  trouble.  Tumor  behind  prostate  soft,  smooth,  size  of  two 
fists.  Enucleation  in  toto  through  anus  and  rectum.  Urethra  not 
injured,  seminal  vesicles  not  seen.  Suture  of  rectum  and  anus.  Pa- 
tient showed  no  recurrence  for  over  three  years.  Death  from  recur- 
rence 4  years  after  operation. 

III.  Verhoogen.""  1898.  1  case,  aged  53.  Pain  in  ano-rectal  re- 
gion. No  urinary  trouble.  Large  spherical  tumor  in  front  of  rectum 
and  beneath  skin.  Operation  through  perineum.  Division  of  mem- 
branous urethra.  Seminal  vesicles  not  removed.  Eecovery.  Peri- 
neal fistula.     Eecurrence.     Death  9  months  later. 

Eemaeks. — A  study  of  these  cases  shows  conclusively  that  partial 
operations  are  of  no  permanent  utility  in  cancer  of  the  prostate. 
Among  the  eleven  cases  attacked  by  enucleation,  excision  of  a  median 
lobe,  or  curettement  through  the  perineum  8  died  of  recurrence,  and 
the  other  three  cases  were  only  followed  1,  3,  and  9  months  respectively. 
The  patient  who  had  lived  9  months  was  reported  well  by  Pousson, 
but  one  of  my  cases  with  large  retroperitoneal,  and  liver  metastases, 
still  feels  absolutely  well  as  far  as  the  pelvic  organs  are  concerned  now 
3%  years  after  prostatectomy. 

Those  operated  upon  by  the  suprapubic  route  were  9.  5  are  reported 
to  have  died  of  a  recurrence,  one  has  a  recurrence  but  is  still  alive, 
one  was  not  followed,  and  two  were  "  fnlly  cured  one  year  after 
operation"  (although  only  a  median  lobe  was  removed  in  each  case), 
an  utterly  improbable  result. 

In  the  three  cases  in  which  the  prostate  was  completely  excised, 
but  the  seminal  vesicles  and  the  adjacent  portion  of  the  vesical  trigone 
were  not  removed,  death  resulted  in  all  three  cases,  once  from  opera- 
tion, twice  from  recurrence. 

Kiister's  case  associated  with  multiple  vesical  tumors  cannot  rightly 
be  included  in  the  results  of  operations  upon  the  cancerous  prostate. 
His  operation  of  complete  excision  of  the  bladder  and  prostate,  with 
transplantation  of  the  ureters  into  the  rectum  ended  in  death  in  5  days. 
When  the  disease  has  spread  beyond  a  localized  invasion  of  the  bladder 
adjacent  to  the  prostate,  radical  operation  is  out  of  the  question,  and 


5-iO  Hugh  R.  Young. 

such  procedures  as  that  of  Kiister  are  useless  if  not  always  certainly 
fatal.  Those  in  which  the  rectum  is  invaded  in  the  prostatic  tumor  are 
in  the  same  categorj^ — useless  and  harmful.  Of  the  five  cases  reported 
only  one  was  cured  and  in  this  case  the  carcinoma  started  in  the 
rectum  and  involved  the  prostate  only  superficially.  Harris'  case  is 
very  interesting,  but  simply  shows  the  truth  of  the  above  statements. 

Sarcoma  of  the  prostate  being  an  entirely  different  disease,  and  ab- 
solutely unlike  in  its  method  of  growth  and  regional  invasion  should 
not  be  considered  in  the  same  class  with  carcinoma,  and  I  cannot 
understand  why  Pousson,  Oraison,  and  others  have  included  such 
eases  in  their  study  of  the  operative  results  upon  cancer  of  the  prostate. 
Cases  of  cancer  of  the  rectum  should  be  excluded  for  the  same 
reasons. 

The  remaining  class — those  in  which  the  seminal  vesicles  and  cuff  of 
the  bladder  were  excised  in  one  piece  with  the  prostate,  comprises  only 
the  four  cases  of  the  writer.  There  has  been  no  operative  mortality. 
One  case,  YIII,  died  six  weeks  after  the  operation  as  a  result  of  an 
operative  mistake — excision  of  the  lower  half  of  the  intramural 
course  of  the  ureters  along  with  the  trigone  because  it  felt  like  it 
was  invaded.  Careful  study  of  the  specimen  removed,  however, 
showed  that  this  was  a  mistake;  that  the  trigone  was  only  invaded 
near  the  prostatic  orifice,  and  that  the  excision  had  been  much  more 
extensive  than  necessary.  This  was  fully  confirmed  at  autopsy  as 
careful  search  failed  to  reveal  any  carcinoma,  regional  or  glandular, 
and  sections  of  structures  adjacent  to  the  prostate  were  negative 
microscopically.  This  case  would  probably  have  been  cured  by  the 
operation,  had  the  valvular  ends  of  the  ureters  not  been  removed. 

Case  YII  died  one  year  later  as  a  result  of  litholapaxy.  The  ope- 
rative specimen  in  this  case  showed  cancer  up  to  the  upper  limit  of 
excision  (above  the  left  seminal  vesicle)  and  the  autopsy  showed  a 
very  small  area  of  carcinoma  behind  the  bladder  above  this  point. 
No  invaded  glands  and  no  other  evidence  of  cancer  was  to  be  found. 
The  case  had  been  subjected  to  a  Bottini  operation  in  another  city 
three  months  before.  A  radical  operation  at  that  time  would  probably 
have  cured  him. 

The  other  two  cases  have  been  operated  on  12  and  13  months  re- 
spectively— too  recently  for  consideration  as  to  ultimate  results.  Both 
are  in  excellent  condition,  however.    It  has  been  surprising  to  see  how 


An  Operation  for  Cancer  of  Prostate.  541 

easily  this  deep  and  extensive  operation  can  be  carried  out  and  par- 
ticularly how  little  post-operative  shock  and  discomfort  are  caused. 

Early  Diagnosis. — The  question  of  cure  depends  largely  upon  early 
diagnosis.  As  shown  above,  this  is  often  difficult,  because  of  the 
absence  of  characteristic  symptoms  and  signs.  When  severe  pain 
and  hematuria  are  associated  with  a  very  hard  prostate  with  upward 
prolongation  of  the  induration  into  the  region  of  the  seminal  vesicles 
on  each  side  the  nature  of  the  disease  is  evident  at  once.  When, 
however,  the  symptoms  are  those  of  ordinary  hypertrophy  and  the 
seminal  vesicles  and  intervesicular  region  is  normal  in  feel  the  diag- 
nosis is  often  difficult.  After  a  careful  review  of  my  cases  I  now 
feel  that  a  markedly  indurated  prostate  causing  obstruction  to  urina- 
tion in  a  man  over  50  years  of  age  should  be  viewed  with  suspicion. 
If  it  is  of  stony  hardness,  it  is  very  apt  to  be  cancerous,  especially  if 
the  cystoscope  shows  little  or  no  enlargement  intravesically  as  in  the 
ordinary  hypertrophy.  In  such  cases  I  proceed  to  expose  the  posterior 
surface  of  the  prostate  as  in  the  ordinary  prostatectomy  operations, 
palpate  the  prostate  directly  and  if  I  find  the  posterior  capsule  more 
adherent  to  the  rectum,  the  tissues  more  hemorrhagic  and  the  con- 
sistence of  the  prostate  much  more  indurated  than  in  the  simple 
hypertrophy,  I  generally  am  able  to  make  the  diagnosis  of  carcinoma 
without  cutting  into  it,  and  proceed  at  once  with  the  radical  operation. 

In  a  recent  case  after  exposing  the  prostate  I  was  still  uncertain 
as  to  malignancy,  and  therefore  made  a  longitudinal  incision  into  the 
prostate  on  each  side  of  the  urethra  as  for  the  usual  prostatic  enuclea- 
tion, and  then  excised  a  slice  of  the  lateral  lobe  parallel  to  the  cut. 
Macroscopic  examination  of  this  showed  the  characteristic  appearance 
of  prostatic  carcinoma — granular  yellowish  dots  and  lines  in  a  paler, 
more  fibrous  stroma,  and  a  frozen  section  made  at  once  and  stained 
showed  definite  adenocarcinoma  invading  the  intra-glandular  stroma. 
It  only  required  6  minutes  to  make  and  stain  the  frozen  section,  and 
I  therefore  propose  the  method  as  one  of  practical  utility  in  all  cases 
where  the  operator  is  in  doubt  as  to  the  character  of  the  enlargement. 
When  the  presence  of  cancer  is  demonstrated  the  capsular  incisions  are 
to  be  closed  at  once  and  the  radical  operation  carried  out. 

In  view  of  the  five  cases  detailed  at  the  beginning  of  this  paper  in 
which  a  mistaken  diagnosis  was  made  I  propose  in  all  cases  in  the 
future  to  study  the  cut  surface  of  the  prostatic  lobes  immediately  after 
their  enucleation  at  the  operating  table  and  if  there  is  the  slightest 


542  Hugh  E.  Young. 

suspicion  of  malignancy  to  have  frozen  sections  prepared  at  once. 
In  very  few  cases  will  the  wait  of  5  minutes  or  more  make  any  differ- 
ence to  the  patient.  In  cases  where  the  prostate  is  indurated,  if  only 
in  part,  this  operating-room  study  of  the  fresh  tissues  is  of  the  greatest 
importance.  I  feel  sure  that  several  of  my  first  six  cases  might  have 
been  saved  by  the  radical  excision  which  would  now  follow  such  a 
course. 

Conclusions. 

The  following  conclusions  may  be  drawn  from  this  study  of  37 
cases.  Carcinoma  of  the  prostate  is  more  frequent  than  usually  sup- 
posed— occurring  in  about  10%  of  the  cases  of  prostatic  enlargement. 
It  may  begin  as  an  isolated  nodule  in  an  otherwise  benign  hyper- 
trophy or  a  prostatic  enlargement  which  has  for  many  years  furnished 
the  symptoms  and  signs  of  benign  hypertrophy  may  suddenly  show 
signs  of  malignant  hypertrophy. 

Marked  induration,  if  only  an  intra-lobar  nodule  in  one  or  both 
lobes  of  the  prostate  in  men  past  50  years  of  age  should  be  viewed 
with  suspicion,  especially  if  the  cystoscope  shows  little  intra-vesical 
prostatic  outgrowth,  and  pain  and  tenderness  are  present. 

The  posterior  surface  of  the  prostate  should  be  exposed  as  for  ordi- 
nary prostatectomy,  and  if  the  operator  is  unable  to  make  a  positive 
diagnosis  of  malignancy,  longitudinal  incisions  should  be  made  on 
each  side  of  the  urethra  (as  in  prostatectomy)  and  a  piece  of  tissue 
excised  for  frozen  sections,  which  can  be  prepared  in  about  six  minutes 
and  examined  by  the  operator  at  once.  If  the  disease  is  malignant, 
the  incisions  may  be  cauterized  and  closed  and  the  radical  operation 
performed. 

Cancer  of  the  prostate  remains  for  a  long  time  within  the  confines 
of  the  lobes,  the  urethra,  bladder  and  especially  the  posterior  cap- 
sule of  the  prostate  resting  inviolate  for  a  considerable  period.  Ex- 
tra-prostatic  invasion  nearly  always  occurs  first  along  the  ejaculatory 
ducts  into  the  space  immediately  above  the  prostate  between  the 
seminal  vesicles  and  the  bladder  and  beneath  the  fascia  of  Denon- 
villiers.  Thence  the  disease  gradually  invades  the  inferior  surface 
of  the  trigone  and  the  lymphatics  leading  toward  the  lateral  walls  of 
the  pelvis,  but  involvement  of  the  pelvic  glands  occurs  late  and  often 
the  disease  metastasises  into  the  osseous  system  without  first  invading 
the  glands. 


An  Operation  for  Cancer  of  Prostate.  543 

Cure  can  be  expected  only  by  radical  measures  and  the  routine  re- 
moval of  the  seminal  vesicles,  vasa  deferentia  and  most  of  the  vesical 
trigone  with  the  entire  prostate  as  carried  out  in  four  cases  by  the 
writer  and  fully  described  by  the  illustrations  is  shown  to  be  neces- 
sary by  the  37  cases,  including  8  autopsies  and  10  operations,  reported 
above. 

The  four  cases  in  which  the  radical  operation  was  done  demonstrate 
its  simplicity,  effectiveness  and  the  remarkably  satisfactory  functional 
results  furnished. 

BiBLIOGEAPHY. 

1.  CourvoisiePl.     Das  Prostatacarcinom.    Inaug.-Diss.    Basel,  1901. 

2.  WoLrr.     Ueber      die     bosartigen      Geschwiilste     der      Prostata, 

insbesondere  liber  die  Carcinome  derselben.     Deutsche  Zeitschr. 
1  Chir.,  Bd.  53. 

3.  Socix  and  Bueckhaedt.     Die  A'erletzungen  und   Krankheiten 

der  Prostata.     F.  Enke,  Stuttgart,  1902. 

4.  Albaerax  and  Halle.     Hypertrophic  et  Xeoplasies  Epitheliales 

de  la  Prostate.    Annales  d.  3Ial.  d.  Org.  Gen.  Hrin.,  1900. 

5.  Poussox.     Cure  Piadicale  du   Cancer  de  la  Prostate.    Annales 

d.  Mai.  d.  Org.  Gen.  Urin.,  1904,  p.  882. 

6.  Hawlet.     Carcinoma  of  the  prostate.     Annals  of  Surgery,  June, 

1904,  p.  892. 

7.  JuLiEX.     Contribution  a  Tetude  clinique  du  cancer  de  la  prostate. 

These  de  Paris,  1895. 

8.  KAUFiTAx^T.     Eef.  Socin  and  Burckhardt. 

9.  GuTOX.     Carcinose  prostato-pelvienne  diffuse.     Le  Bulletin  ^Ledi- 

cal,  1887,  Vol.  I,  p.  1339. 

10.  BiLLEOTH.     Carcinoma  der  Prostata.  Chir.  Erfahrungen,  Ziirich, 

1860-67.     Arch.  f.  klin.  Chir.,  1869,  Bd.  X,  S.  548. 

11.  Fexwick.     Primary  malignant   Disease   of  the  prostate   gland. 

Edinburgh  :\Iedical  Journal,  1899,  p.  16. 

12.  Haeeisox.     Lancet,  September  20,  1884. 

13.  Heath.     Cited  by  Pousson. 

14.  Adexot.     Tumeur  maligne  de  la  prostate;  prostatectomie  peri- 

neale.    Annales  d.  Mai.  d.  Org.  Gen.  Urin.,  1901,  p.  596. 

15.  Geeexe.     Cancer  of  Prostate.     ISTew  York  Medical  Journal,  Octo- 

ber 24,  1903,  p.  285. 


544  Hugh  R.  Young. 

16.  Belfield.     a  Case  of  Cancer  of  the  Prostate.     Journal  Ameri- 

can Med.  Assoc,  1888,  p.  120. 

17.  Steix.     Archiv  fur  Klin.  Chir.,  1889,  Vol.  39,  p.  537. 

18.  Paeoxa.     Gazz.  Med.  Lombard,  1891,  p.  265. 

19.  vox  Frisch.     Die  Krankheiten  der  Prostata.     Wien,  1898. 

20.  Haeeisox.     British  Medical  Journal,  July  4,  1903,  p.  1. 

21.  Jacobsox.     Contributions  to  the  Surgery  of  Malignant  Diseases 

of  the  Prostate.     Annals  of  Surgery,  1901,  VoL  XXXIII. 

22.  KtJSTEE.     Total  Extirpation  of  the  Prostate  and  Bladder.    Archiv. 

fiir  Klin.  Chir.,  1891,  Bd.  42,  S.  864. 

23.  Hakeis.     Annals  of  Surgery,  1902,  Vol.  XXXVI,  p.  509. 

24.  Leiseixk.     Arch,  fiir  Klin.  Chir.,  1882, 

25.  Fuller.     Journal   of    Cutaneous   and    Genito-urinary   Diseases, 

1898,  p.  581. 

26.  Demaequay.     De  I'Ablation  partielle  ou  totale  de  I'lntestin  Piec- 

tal  avec  Ablation  Partielle  ou  Totale  de  la  Prostate.     Gazz. 
Medicale  de  Paris,  August  28,  1873,  pp.  383  and  410. 

27.  Depage.     Cited  by  Verhoogen,  30. 

28.  Spaxtox.     Sarcoma  of  the  Prostate.     The  Lancet,  1882,  Vol.  77. 

29.  BuECKHARDT.    Ceutr.  der  Ham  u.  Sex.  Org.,  Bd.  V,  1894,  S.  152. 

30.  A'erhoogex.     Centralb.   fiir  d.   Krank.   d.   Harn  u.   Sex.   Org., 

1898,  Bd.  IX,  S.  19 

APPEXDIX. 

A  Detailed  Eepoet  of  64   Cases  oe  Caxcee  of  the  Prostate 

Grouped  Accordixg  to  the  Treatmext  Employed. 

Since  the  preceding  article  was  written  one  year  ago,  many  new 
cases  of  carcinoma  of  the  prostate  have  appeared  in  our  practice,  and 
owing  to  the  great  importance  of  the  subject,  particularly  as  regards 
the  early  diagnosis  and  the  treatment  appropriate  for  both  early  and 
late  cases,  I  have  decided  to  publish  the  details  of  all  the  cases,  now 
64  in  number. 

We  have  not  had  time  to  make  a  careful  analytical  study  as  regards 
the  history  of  the  disease,  the  symptomatolog}-,  the  condition  and  find- 
ings on  admission,  but  a  cursory  review  of  the  cases  shows  that  the 
conclusions  tabulated  in  the  previous  article  are  in  the  main  entirely 
correct  and  apply  with  fair  accuracy  to  the  64  cases  herein  reported. 


An  Operation  for  Cancer  of  Prostate.  545 

These  additional  cases  have  strengthened  our  confidence  in  the  pos- 
sibility of  making  early  diagnosis  of  carcinoma  of  the  prostate,  and  of 
curing  these  cases  permanently  by  a  very  thorough  radical  operation 
as  described  in  the  preceding  paper.  Unfortunately  no  sufficiently 
early  cases  have  presented  themselves,  but  further  study  of  the 
pathology  and  the  results  obtained  in  Cases  3  and  4,  confirm  our 
opinion  as  to  the  possibility  of  completely  eradicating  the  disease  if 
the  technique  described  above  is  followed.  ■ 

In  the  present  report  of  cases  in  detail,  grouping  as  regards  the 
treatment  employed  has  been  followed. 

A.  Six  cases  in  which  the  operation  of  radical  excision  was  employed . 

B.  Eight  cases  in  which  partial  perineal  prostatectomy  was  used 

C.  Two  cases  in  which  suprapubic  prostatectomy  was  used 

D.  Seven  cases  in  which  the  Bottini  operation  was  used. 

E.  Two  cases  in  which  castration  was  performed 

F.  Five  cases  in  which  suprapubic  cystotomy  for  drainage  was  em- 

ployed    

G.  Two  cases  in  which  perineal  drainage  was  employed 

H.     Sixteen  cases  treated  by  catheterization 

I.     Eighteen  cases  in  which  the  catheter  was  not  used 

A.     The  Eadioal  Operation.     Six  Cases. 

In  six  cases  the  radical  operation  described  in  another  portion  of 
this  volume  was  performed.  Four  of  these  cases  have  been  described 
in  detail  in  the  paper  referred  to,  and  will  not  be  given  here.  These 
cases  were: 

Case  1  (see  previous  paper,  Case  VII). — Carcinoma  of  prostate  involving 
the  bases  of  the  seminal  vesicles.  Radical  excision  of  prostate,  vesicles, 
vasa  deferentia  and  cuff  of  bladder.  Anastomosis  of  anterior  wall  of 
bladder  and  urethra.  Recovery.  Closure  of  perineal  fistula,  satisfactory 
urination  through  anterior  urethra  with  no  incontinence  at  night.  Con- 
stant dribbling  during  the  day.  Painful  urination  coming  on  five  months 
after  the  operation.  Examination  at  the  end  of  nine  months  showed 
three  vesical  calculi.  Litholapaxy  performed.  This  was  followed  by  per- 
ineal and  prevesical  abscess,  septicemia  and  death. 

Autopsy  showed  only  a  minute  area  of  carcinoma  in  the  pelvis. 

Case  2  (see  Case  VIII). — Carcinoma  of  prostate  involving  the  seminal 
vesicle.  Radical  operation.  Recovery.  Death  seven  weeks  later  from 
uremia. 

Autopsy  showed  double  ureteritis  and  pyelitis,  chronic  diffuse  nephritis, 
cardiac  hypertrophy  and  dilatation,  chronic  myocarditis,  endocarditis  and 


546  Hugh  H.  Young. 

emphysema  of  the  lungs.  Careful  examination  failed  to  reveal  any  re- 
maining carcinoma.  The  operation  had  been  successful  in  removing  all 
malignant  disease. 

Case  3. — Cancer  of  prostate  involving  seminal  vesicles  and  anterior 
portion  of  trigone.  Recovery.  Restoration  of  urination  through  anterior 
urethra.     Well  eleven  months  after  the  operation  (see  Case  IX). 

Case  4. — Carcinoma  of  prostrate  and  seminal  vesicles.  Radical  opera- 
tion. Recovery.  Restoration  of  urination  through  urethra.  Well  one 
year  after  operation  (see  case  X). 

Since  the  four  cases  mentioned  above  were  reported  the  radical  op- 
eration has  been  done  in  two  cases.  In  the  first  case  the  bladder  and 
the  upper  portions  of  the  seminal  vesicles  were  thought  to  be  free 
from  disease,  and  a  hopeful  prognosis  was  given  and  operation  there- 
fore attempted.  The  patient  died  of  shock  and  autopsy  showed  ex- 
tensive involvement  of  the  peritoneum  and  the  retroperitoneal  lymph 
glands.  The  malignant  disease  of  these  structures  had  not  been  sus- 
pected, and  was  evidently  the  cause  of  the  markedly  lowered  vitality 
of  the  patient,  and  death  from  shock  of  operation,  as  in  none  of  the 
other  cases  was  there  more  than  slight  shock  after  operation. 

In  the  second  case  the  anterior  portion  of  the  left  lateral  lobe  pre- 
sented a  peculiar,  markedly  indurated  lobule,  which  on  section  at  op- 
eration showed  the  typical  appearance  of  carcinoma.  Xo  freezing 
microtome  was  at  hand  (the  operation  being  performed  elsewhere  than 
at  the  Johns  Hopkins  Hospital),  and  although  the  rest  of  the  prostate 
looked  benign,  after  consultation  with  other  surgeons  present,  it  was 
thought  best  to  perform  the  radical  operation.  Subsequent  micro- 
scopic examination  of  the  specimen  showed  a  hemorrhagic  prostatitis 
in  the  suspicious  area,  and  although  a  few  places  suggest  malignancy 
it  seems  probable  that  the  process  is  benign.  The  patient  is  in  good 
condition  and  is  comfortable,  but  suffers  from  incontinence  of  urine 
(much  to  my  distress). 

These  two  cases  are  as  follows : 

Case  5. — Carcinoma  of  prostate  and  seminal  vesicles.  Urinary  symptoms 
for  eight  months.  Radical  operation.  Death  from  shock.  Autopsy  showed 
extensive  intraperitoneal  and  glandular  metastases. 

No.  1052.     M.  G.,  age  75,  widowed,  admitted  September  25,  1905. 

Complaint. — "  Frequent  urination." 

No  history  of  gonorrhcea.  One  year  ago  patient  began  to  have  pain  in 
the  right  side  just  below  the  costal  margin  and  radiating  from  there 
beneath  the  ribs  to  the  back.  A  little  later  a  similar  pain  appeared  on 
the  left  side. 


An  Operation  for  Cancer  of  Prostate.  547 

About  eight  months  ago  he  first  began  to  get  up  at  night  to  urinate,  but 
after  that  urination  became  rapidly  more  frequent  and  difficult  and  after 
a  few  weeks  he  was  voiding  four  or  four  times  during  the  night.  During 
the  past  six  months  urination  has  been  extremely  difiicult,  but  he  has 
had  no  pain  in  the  region  of  the  bladder  or  rectum  until  a  month  ago 
when  he  began  to  have  a  severe  burning  during  urination  and  particularly 
at  the  end.  He  has  also  had  a  severe  pain  in  the  lumbar  region  on  both 
sides,  and  for  two  days  has  had  pain  in  the  left  thigh  and  knee.  He 
has  had  no  pain  in  the  hips,  rectum,  testicles  or  groins.  During  the 
past  three  weeks  he  has  lost  16  pounds  and  become  very  weak.  He  has 
not  had  complete  retention,  no  hematuria,  nor  gravel. 

Status  prwsens. — Micturition  every  20  minutes  to  one  hour,  not  very 
difficult,  but  the  stream  is  small  and  he  has  to  strain  and  there  is  often 
dribbling  at  the  end.  Burning  pain  in  the  urethra,  worse  at  the  end 
of  urination.  Pain  in  the  lumbar  region  on  both  sides,  and  in  left  thigh 
and  knee. 

Sexual  powers. — Sexual  desire  and  erections  have  been  absent  for  two 
years. 

Examination. — The  patient  is  a  sturdy  looking  man  with  mucous  mem- 
branes of  good  color.  The  heart  and  lungs  are  negative.  The  abdomen 
is  negative.  Glands  are  palpable  in  both  inguinal  regions  and  a  complete 
right  inguinal  hernia  is  present. 

Genitalia. — The  left  epididymis  is  slightly  indurated. 

Rectal. — The  prostate  is  equilaterally  enlarged  to  a  moderate  degree. 
It  is  hard,  but  slightly  elastic  and  not  stony.  The  right  seminal  vesicle 
is  not  enlarged  nor  indurated.  The  left  vesicle  is  also  negative,  but  the 
left  lobe  of  the  prostate  extends  further  up  and  the  induration  may  involve 
the  lower  portion  of  the  seminal  vesicle.  Above  the  prostate  between 
the  seminal  vesicles  the  tissues  are  firm,  and  on  the  right  side  several 
hard  cords  can  be  felt  along  the  pelvic  wall.  No  enlarged  glands  can 
be  felt.     The  rectal  mucosa  is  soft  and  not  adherent. 

Cystoscopic. — A  coude  catheter  cannot  be  introduced  owing  to  obstruction 
at  the  apex  of  the  prostate.  A  silver  catheter  passes  with  ease  and  with- 
draws 80  cc.  residual  urine.  The  bladder  capacity  is  360  cc.  Study  of 
the  prostatic  orifice  shows  an  irregular  enlargement  all  around  the  urethra, 
the  projection  from  the  left  lateral  lobe  being  more  irregular  than  the 
right  and  distinctly  fissured,  but  covered  with  smooth  mucous  membrane. 
The  median  portion  was  moderately  enlarged,  and  extending  upward  and 
to  the  left  from  it  is  an  elevation  of  the  trigone  continuous  with  the 
median  prostatic  bar  and  also  presenting  an  irregular  somewhat  nodular 
surface,  this  extends  outward  as  far  as  the  usual  location  for  the  left 
ureteral  orifice  which  cannot  be  seen.  The  right  ureteral  orifice  is  situated 
in  a  normal  ridge  and  is  normal  in  appearance.  The  bladder  is  moderately 
trabeculated  and  inflamed.  No  ulceration,  no  calculus,  no  polypoid  intra- 
vesical neoplasm  present.  With  finger  in  rectum  and  cystoscope  in  urethra 
it  is  impossible  to  feel  the  beak,  owing  to  induration  beneath  the  trigone, 


548  Hugh  H.  Young. 

and  the  median  and  suburethral  portions  of  the  prostate  are  considerably 
increased. 

Urinalysis. — Clear,  acid,  1018,  albumin  in  small  amount,  no  sugar,  no 
shreds,  microscopically  negative. 

Remark. — The  induration  on  prostatic  examination  at  once  suggested 
malignancy.  The  elevation  of  the  trigone  seen  with  the  cystoscope  by 
growth  continuous  with  the  median  prostatic  enlargement  is  at  once 
confirmatory  of  carcinoma.  The  left  ureteral  orifice  cannot  be  seen  and 
the  disease  is  evidently  close  to  it.  Owing  to  absence  of  induration  in  the 
region  of  the  seminal  vesicles,  the  absence  of  pelvic  glands,  the  radical 
operation  was  thought  to  be  advisable. 

Operation  October  13,  1905. — Ether.     Radical  operation  for  the  cure  of 
cancer  of  the  prostate.     Excision  of  the  prostate  with   its   capsule  and 
urethra  intact,  a  portion  of  the  membranous  urethra,  a  cuff  of  the  bladder, 
nearly  all  of  the  trigone  including  5  mm.  of  the  left  ureter,  the  seminal 
vesicles  and  about  5  cm.  of  the  vasa  deferentia,  all  in  one  piece.     Anas- 
tamosis  of  the  bladder  to  the  membranous  urethra,  a  complete  closure  of 
the  vesical  opening.     The  technique  followed  was  that  described  in  the 
Johns  Hopkins  Biilletin  for  October,  1905.     The  incisions  were  very  little 
larger  than  cases  of  perineal  prostatectomy  for  benign  hypertrophy,  and 
the  levator  ani  muscles  were  not   divided.     The  perineal   fissures   were 
found  to  be  very  hyperemic  and  there  was  considerable  hemorrhage  before 
reaching  the  prostate.     The  separation  of  the  rectum  from  the  prostate 
was  difficult  owing  to  adhesions.     Examination  of  the  posterior  surface 
of   the    prostate    revealed    considerable    induration    with    irregularity    of 
surface,  making  the  diagnosis  positive.     There  was  no  evidence  of  exten- 
sion of  the  disease  beyond  the  capsule  and  the  upper   portions  of  the 
seminal  vesicles  seemed  to  be  healthy,  the  radical  operation  was  therefore 
begun.     On   exposing  the  trigone  the  mucous   membrane   was   found   re- 
duplicated and  elevated  in  a  mass  continuous  with  the  median  portion  of 
the    prostate,    and   extending   out   to   the    orifice    of   the    right    ureter    as 
described  in  the  cystoscopic  examination.     The  interureteral  bar  formed 
a  prominent  transverse  ridge  behind  which  there  was  a  fairly  deep  pouch, 
the  mucous   membrance,   however,  was   everywhere   soft   and   normal   in 
appearance.     The   line   of   incision   was    carried    across   the   trigone   just 
below  the  right  ureteral  orifice  above  the  ligamentum  interuretericum  and 
just  above  the  rounded  elevation  described  above  in  the  region  of  the  left 
ureteral    orifice.     Later    examination    showed    that   about    5    mm.    of   the 
left  ureter  had  been  excised,  the  orifice  being  in  the  upper  end  of  the 
elevation  of  mucous  membrance.     The  upper  end  of  the  left  seminal  vesicle 
was  very  adherent  to  the  perineum  and  in  freeing  it  a  portion  of  the 
latter  was  removed,  examination  showed  that  it  was  thickened,  rough  and 
evidently   involved.     No   enlarged   glands   or   indurated   lymphatics   were 
found  in  the  pelvis,  and  the  bladder  was  perfectly  healthy  above  the  point 
of  excision.     No  diflQculty  was  experienced   in  anastomosing  the  vesical 
opening  with  the  membranous  urethra,  and  the  bladder  was  closed  with 


An  Operation  for  Cancer  of  Prostate.  549 

ease  with  alternating  sutures  of  catgut  and  silkworm  gut.  The  wound 
was  closed  as  usual.  The  patient  lost  more  blood  than  is  usual  and  at 
the  end  of  operation  his  condition  was  reported  bad,  the  volume  of  the 
pulse  was  weak,  125  to  the  minute.  Respiration  was  more  alarming  than 
the  pulse.  He  had  been  infused  early  in  the  operation,  but  only  500  cc. 
had  been  introduced.  Towards  the  end  of  the  operation  he  was  transfused 
about  700  cc.  of  salt  solution  being  introduced  into  one  of  the  veins,  this 
was  followed  by  distinct  improvement  in  the  pulse,  but  the  respiration 
remained  bad  and  in  a  short  time  artificial  respiration  was  resorted  to. 
Various  stimulants  were  used  but  despite  these  measures  the  patient  grew 
weaker  and  died  about  two  hours  after  the  operation. 

Pathological  examination. — The  specimen,  G.  U.  192,  consists  of  the 
entire  prostate,  both  seminal  vesicles,  the  lower  end  of  the  vas  deferens 
on  each  side,  cuff  of  the  bladder,  and  prostatic  urethra.  On  the  left 
seminal  vesicle  there  is  a  small  piece  of  peritoneum  attached  which  shows 
little  yellow  dots  suggesting  metastases.  The  middle  lobe  is  not  much 
enlarged  and  the  prostatic  urethra  at  its  opening  appears  dilated.  Serial 
gross  sections  of  the  prostate  show  a  half  moon  shaped  zone  of  prostatic 
tissue  which  has  the  typical  naked  eye  appearance  of  carcinoma,  and 
situated  towards  the  posterior  surface  of  the  prostate.  The  anterior  por- 
tion of  the  lobes  has  the  appearance  of  benign  hypertrophy.  Towards 
the  upper  end  of  the  prostate  the  carcinoma  area  broadens  and  then 
travels  upwards  into  the  region  of  the  seminal  vesicles  and  involving 
both.  The  median  portion  of  the  prostate,  which  is  small,  seems  appar- 
ently not  involved.  At  autopsy  it  was  found  that  direct  extension  of  the 
disease  from  the  left  peritoneal  cavity  had  occurred,  and  there  were  exten- 
sive metastases  in  the  pelvic  and  retroperitoneal  glands  as  far  up  as  the 
bifurcation  of  the  aorta. 

Microscopical  examination. — The  sections  from  the  anterior  portion  of 
the  lateral  lobes  show  a  benign  adenomatous  hypertrophy.  Section  from 
the  prostate  in  the  area  which  showed  carcinoma  with  the  naked  eye 
shows  an  adenocarcinoma,  within  most  places  a  rather  large  amount  of 
stroma.  The  acini  are  often  grouped  together,  are  usually  very  small 
and  lined  by  an  epithelium  showing  the  characteristic  involution  changes. 
In  places  the  carcinoma  is  of  a  distinctly  infiltrating  type,  the  stroma  being 
largely  obscured  by  the  epithelial  invasion.  Sections  from  the  middle  of 
the  seminal  vesicles  show  carcinoma  of  the  same  type  invading  the 
walls  and  infiltrating  the  surrounding  tissue.  There  is  more  stroma,  how- 
ever, than  in  sections  from  the  prostate.  A  section  from  the  middle  lobe 
which  on  naked  eye  examination  was  thought  not  to  contain  carcinoma,  on 
microscopic  examination  shows  a  definite  adenocarcinoma  in  which  the 
acinous  type  is  extremely  well  preserved. 

Diagnosis. — Adenocarcinoma  becoming  infiltrating,  with  extensive  in- 
volvement of  the  vesicles  and  direct  extension  to  the  peritoneal  cavity 
from  the  left  seminal  vesicle  metastatic  pelvic  and  retroperitoneal  glands. 


550  Hugli  H.  Young. 

Case  6. — Considerable  enlargement  of  prostate  with  large  indurated 
loiule  projecting  from  right  lateral  lobe.  Clinical  diagnosis  benign.  At 
operation  tissue  removed  strongly  suggested  cancer  and  as  freezing  micro- 
tome tvas  not  at  hand  a  radical  operation  was  done. 

No.  1126.     G.  W.  F.,  aged  67,  widowed,  admitted  December  28,  1905. 

Complaint. — "  Frequency  and  difBculty  of  urination." 

No  history  of  gonorrhoea. 

Twelve  years  ago  the  patient  had  an  attack  of  irritability  of  the  bladder 
with  very  frequent  urination.  Examination  of  the  prostate  showed  slight 
enlargement,  and  a  diagnosis  of  prostatitis  was  made.  After  three  weeks 
he  was  perfectly  well,  and  remained  so  until  seven  years  ago,  when  he 
began  to  have  slight  difBculty  in  urination  and  had  to  get  up  once  or 
twice  at  night  to  urinate.  Since  then  urination  has  gradually  become 
more  frequent  and  difficult,  and  during  the  past  year  he  has  had  to  arise 
four  or  five  times  every  night,  but  has  not  had  complete  retention.  During 
the  past  six  weeks  his  symptoms  have  been  worse;  urination  being  very 
difficult  and  frequent.  He  has  had  no  severe  pain,  but  when  the  bladder 
becomes  full  he  has  an  imperative  desire  to  urinate  and  considerable 
discomfort,  and  unless  he  voids  at  once  there  is  usually  an  involuntary 
escape  of  urine.  He  gets  up  about  six  times  at  night  and  voids  about 
every  hour  during  the  day.  There  has  been  no  pain  in  rectum,  hips, 
thighs  or  perineum.     He  has  not  lost  weight. 

Sexual  powers. — ^No  note  made.     No  hematuria. 

Examination. — The  patient  is  a  sturdy-looking  man  with  lips  of  good 
color.    No  arteriosclerosis.    Pulse  regular  and  of  good  volume. 

Genitalia. — Negative. 

Rectal. — The  prostate  is  considerably  hypertrophied,  forming  a  round 
mass  about  the  size  of  a  medium  sized  orange.  The  surface  is  smooth 
and  regular  with  the  exception  of  the  anterior  portion  of  the  right  lateral 
lobe,  from  which  there  is  a  round  projection  about  the  size  of  a  cherry 
and  distinctly  firmer  than  the  rest  of  the  prostrate,  but  not  markedly 
indurated.  The  prostatic  capsule  is  smooth  and  the  consistence  is  gen- 
erally elastic,  in  places  soft.  The  seminal  vesicles  are  apparently  not 
enlarged  nor  indurated.  The  prostrate  is  not  tender.  No  enlarged  glands 
are  to  be  felt.  The  rectum  is  soft  and  not  adherent.  The  prostatic  secre- 
tion contains  very  few  pus  cells,  a  few  granule  cells,  and  is  mostly  com- 
posed of  spermatozoa,  some  of  which  are  motile. 

Urinalysis. — Acid,  1022,  no  albumin,  no  sugar.     Microscopically  negative. 

Cystoscopic. — A  coude  catheter  could  not  be  passed  owing  to  obstruction 
in  the  region  of  the  middle  lobe.  A  silver  catheter  passed,  but  produced 
some  hemorrhage.  Considerable  amount  of  residual  urine  is  found  pres- 
ent, record  of  amount  lost.  An  attempt  was  made  to  pass  a  cystoscope, 
but  without  success,  owing  to  obstruction  in  the  median  portion  of  the 
prostate. 

IJote. — The  general  character  of  the  prostate  was  that  of  a  benign 
adenomatous  hypertrophy.     The  indurated  nodule  in  the  anterior  portion 


An  Operation  for  Cancer  of  Prostate.  551 

of  the  right  lobe  made  us  suspicious  of  carcinoma,  and  it  was  very  un- 
fortunate that  no  cystoscopic  examination  could  be  made  on  account  of 
its  diagnostic  value. 

Operation  Decem'ber  29,  1905. — Ether.     The  prostate  was  exposed  through 
the  usual  technique,  and  the  tractor  was  inserted  with  ease.     The  rectum 
was  fairly  adherent  but  was  finally  separated  from  posterior  surface  of 
the  capsule,  leaving  a  smooth  white  surface.     Examination  of  the  prostate 
showed  a  prominent  rounded  lobule  projecting  from  the  left  lateral  lobe 
in  its  anterior  portion  which  was  covered  with  smooth  mucous  membrane, 
but  was  distinctly  harder  than  the  rest  of  the  prostate.     Bilateral  capsular 
incisions  were   made   as   for   the   usual    prostatectomy.     The   cut   surface 
on  the  left  side  presented  no  unusual  aspect.     On  the  right  side  the  cut 
surface  showed  small   irregular  areas  of  hemorrhage   in  a  hard   stroma 
with  small  grayish  dots  and  lines,  granular  in  appearance  studding  the 
surface.     The  sensation  to  the  knife  in  making  the  incision  was  much 
firmer  and  rougher  than  usual.     The  picture  described  above  was  sharply 
circumscribed  and  confined  to  an  area  about  2  cm.  long  and  1%  cm.  deep. 
Beyond  this  the  cut  surface  presented  the  usual  appearance  of  a  benign 
hypertrophy.     As  no  freezing  microtome  was  at  hand  the  operator  decided 
to   excise   this   portion    of   the   right   lateral   lobe   with    its    capsule.     Ex- 
amination   of   the   suspicious   portion   by   means    of   further    incisions    in 
the  tissue  while  not  positively  characteristic  of  carcinoma  was  so  very 
suspicious  that  it  was  thought  advisable  to   do  as  radical  an  operation 
as   possible    on    the    provisional    diagnosis    of    carcinoma.      The    operator 
then    excised    all    the    lateral    lobes    of    the    prostate    with    the    capsule, 
the    floor    and    most    of    the    lateral    walls    of    the    urethra.       The    lower 
portion   of  the   right   seminal   vesicle   was   removed   with   this   mass,    an- 
examination    of    the    tissue    between    it    and    the    deeper    portion    of   the 
right  lateral  lobe,  showing  that  it  was   quite  hard   and   very   suspicious 
of  carcinoma  on  section.     It  was  therefore  thought  advisable  to  remove 
still  more  tissue.     An  irregular  area  of  vesical  neck   including  most  of 
the  trigone  was  then  excised,  more  difficulty  being  experienced  than   in 
the  typical  operation  for  carcinoma,  owing  to  the  fact  that  the  traction 
was  imperfect,  the  bladder  being  caught  by  forceps  in  various  places.     The 
upper   portion   of  the   left   seminal   vesicle   was    not   excised.     The   right 
seminal  vesicle  was  removed  in  two  pieces  along  with  the  vas  deferens. 
Examination  of  the  upper  limits  of  the  tissue  removed  showed  no  sug- 
gestion of  malignancy.     The  anterior  portion  of  the  prostatic  capsule  and 
the  roof   of  the  urethra  attached   to   it  were   left   intact.     The   operator 
hoped  that  this  would  be  of  assistance  in  closing  the  vesical  wound,  but 
it  proved  to  be  a  hindrance,  and  the  vesical  urethral  anastomosis  was  much 
more  difficult  to   accomplish.     It  was  finally  possible,  however,  to   draw 
down  the  lateral  walls  of  the  bladder  and  suture  them  to  the  membranous 
urethra  and  to  each  other  in  the  median  line  posteriorly,  thus  completely 
closing  the  vesical  wound.     Interrupted  catgut  and  silkworm  gut  sutures 
were  used,  the  latter  being  left  uncut  so  that  the   ends   of  the  sutures 
Vol.  XIV.— 38. 


oo2  Hugh  E.  Young. 

projected  from  the  wound  for  future  removal.  After  packing  the  retro- 
vesical cavity  lightly  with  gauze  and  drawing  the  levators  together  with 
single  sutures  of  catgut,  the  skin  wound  was  closed  partially  with  inter- 
rupted sutures  of  catgut.  The  urethra  was  drained  with  a  large  rubber 
catheter  which  was  held  in  place  with  adhesive  plaster. 

Convalescence. — The  patient  reacted  well,  and  his  pulse  did  not  rise 
above  76  during  the  night  after  the  operation.  He  was  infused  on  the 
table  and  again  at  8  p.  m.  The  catheters  were  removed  from  the  urethra 
on  the  seventh  day,  and  after  that  urine  began  to  come  through  the 
perineal  wound  for  the  first  time.  He  was  put  in  a  wheel-chair  on  the 
seventh  day  and  walking  about  the  ward  on  the  tenth  day.  The  rectal 
sphincter  was  weak,  and  the  perineal  fistula  was  very  slow  in  healing. 
The  temperature  arose  occasionally  in  the  evening;  on  January  3  and  4 
it  rose  to  101.5°,  after  that  it  was  normal  until  January  11,  but  then  for 
a  week  had  a  daily  rise  of  temperature  occasionally  reaching  102°.  The 
The  fistula  closed  on  February  13,  but  the  temperature  rose  to  102.8°.,  and 
after  two  days  the  fistula  opened  again,  pus  was  discharged  and  the 
temperature  fell  to  normal.  The  perineal  fistula  closed  finally  on  Feb- 
ruary 25,  58  days  after  the  operation,  but  he  continued  to  have  slight 
elevation  of  temperature  in  the  evening. 

March  S,  1906. — The  perineal  fistula  has  remained  closed  since  February 
25.  He  is  able  to  retain  urine  for  1%  hours  when  sitting  quietly,  when 
walking  about  small  amounts  of  urine  escape  at  intervals.  He  has  no 
pain  in  bladder,  urethra,  rectum  or  region  of  the  kidneys.  The  urine  is 
acid,  sp.  gr.  1012,  there  is  a  small  amount  of  albumin.  Microscopically 
pus  and  epithelial  cells,  bacilli  and  cocci. 

May  29,  1906. — Letter  from  physician.  "  The  patient's  general  condition 
is  very  good  and  he  is  able  to  attend  to  his  duties.  He  has  no  control  over 
his  urine,  but  there  is  no  flow  during  the  night.  After  arising  in  the 
morning  there  is  a  frequent  discharge  of  urine  during  the  first  hour." 

Pathological  examination. — The  specimen  G.  U.  224,  consists  of  six 
pieces  of  prostatic  tissue,  the  prostatic  urethra  middle  lobe  and  adjoining 
parts  of  the  lateral  lobe  together  with  the  lower  end  of  the  right  seminal 
vesicle  form  one  piece.  The  left  lateral  was  removed  in  one  piece  and 
the  right  in  two.  Two  of  the  pieces  consist  of  bladder  with  portions  of 
the  vasa  and  vesicles  attached.  On  the  posterior  surface  of  the  right 
lateral  lobe  just  beneath  the  capsule  there  is  a  firm  tissue  which  on  section 
is  granular  and  hemorrhagic.  It  extends  from  the  periphery  inwards 
about  1  or  2  cm.  This  portion  of  tissue  was  considered  suggestive  of 
carcinoma  at  operation,  but  when  the  specimen  was  examined,  24  hours 
later,  the  appearance  of  the  above  described  area  was  considerably  changed 
and  did  not  suggest  carcinoma  nearly  so  strongly,  rather  suggesting  pros- 
tatitis limited  to  the  peripheral  portion  of  the  glands.  The  deeper  portion 
of  the  gland  is  lobulated,  apparently  largely  glandular  with  numerous 
small  cysts  and  dilated  acini.  The  left  lateral  lobe  about  its  periphery 
presents  the  same  appearance  as  the  right  lateral,  consisting  of  a  layer 


An  Operation  for  Cancer  of  Prostate.  553 

of  tissue  which,  is  firm,  somewhat  granular  looking,  and  probably  largely 
fibrous  tissue  with  small  hemorrhagic  areas  here  and  there.  Numerous 
small  pin-point  sized  prostatic  calculi  seen.  The  deep  portion  of  the 
gland  is  lobulated  and  has  the  same  appearance  as  the  deeper  portion 
of  the  right  lateral.     The  seminal  vesicles  are  soft  and  seem  normal. 

Microscopical  examination. — The  hypertrophy  is  for  the  most  part  an 
adenomatous  one  with  some  areas  where  the  fibro-muscular  element  pre- 
dominates. The  glandular  tissue  is  largely  arranged  in  spheroidal  lobules, 
the  acini  showing  the  usual  characteristic  appearance.  Within  the  area 
considered  suggestive  of  carcinoma,  clinically,  there  is  found  a  rather 
excessive  amount  of  fibro-muscular  tissue  with  considerable  chronic 
prostatitis.  Throughout  other  portions  of  the  gland  there  are  here  and 
there  small  areas  of  prostatitis.  The  hypertrophy  is  a  glandular  one  with 
formation  of  spherical  lobules  and  comparatively  small  amount  of  stroma 
which  contains  more  fibrous  tissue  than  muscular.  Sections  from  the 
lower  end  of  the  seminal  vesicle  show  them  to  be  apparently  normal. 
No  evidence  of  carcinoma  in  any  part  of  the  prostate.  The  prostatitis  is 
almost  entirely  limited  to  the  condensed  peripheral  portion  of  the  gland. 
The  central  hypertrophied  portion  showing  only  a  few  minute  areas  of 
mild  prostatitis. 

B.     Conservative  Perineal  Prostatectomy.     Eight  Cases. 

In  eight  cases  the  technique  employed  in  the  removal  of  benign 
prostatic  enlargements  through  the  perineum  and  described  in  another 
portion  of  this  volume,  has  been  employed  (with  the  exception  of  one 
case  in  which  the  Alexander  operation,  perineal  prostatectomy  with 
the  aid  of  a  preliminary  suprapubic  cystotomy,  was  performed). 

In  only  one  of  these  cases  was  the  positive  diagnosis  of  carcinoma 
made  before  operation  (Case  13),  the  operation  being  performed 
with  the  hope  of  relieving  obstruction  and  doing  away  with  the  neces- 
sity of  catheterization  which  could  not  be  carried  out  by  the  patient. 

In  Cases  10,  11  and  12,  examination  of  the  tissues  at  operation  sug- 
gested malignancy,  but  the  operator  was  not  prepared  to  perform  a 
radical  operation  in  one  case  and  the  other  two  cases  were  too  old  and 
weak.  In  the  other  four  cases  carcinoma  was  not  suspected  at  opera- 
tion. 

All  of  these  cases  with  the  exception  of  Case  14,  have  been  operated 
on  by  the  writer.  Among  these  eight  cases  there  has  been  one  death 
following  the  operation  (Case  13).  Two  cases  have  died  since  the 
operation,  both  having  suffered  considerable  pain  and  retention  of 
urine  after  operation  (Cases  7  and  8).  In  one  case  (Case  9),  there 
has  been  a  recurrence  of  the  obstruction  and  residual  urine,  but  the 
patient  is  comfortable  and  voids  urine  with  ease. 


554  Eugli  H.  Young. 

The  results  obtained  in  these  cases  have  been  surprisingly  good,  and 
makes  one  wonder  whether  it  would  not  be  advisable  in  many  cases  of 
carcinoma  of  the  prostate,  where  the  radical  operation  is  out  of  the 
question,  and  catheterization  difficult  or  painful,  to  perform  conserva- 
tive perineal  prostatectomy  to  relieve  the  obstruction  rather  than 
suprapubic  drainage.  The  excellent  results  obtained  in  four  cases 
would  seem  to  indicate  this. 

These  cases  are  as  follows : 

Case  7. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  three 
years.  Frequency  of  urination,  catheterism.  Perineal  prostatectomy. 
Death  19  months  later. 

No.  227.    T.  R.,  age  66,  married,  admitted  August  9,  1898. 

Complaint. — "  Retention  of  urine,  catheterism." 

The  patient  had  had  gonorrhoea  at  the  age  of  25  years,  and  seven  years 
ago  a  second  attack  characterized  by  marked  frequency  of  urination,  tenes- 
mus and  epididymitis.  The  present  illness  began  three  years  ago  with 
difficulty  and  frequency  of  urination,  which  gradually  increased.  Five 
months  ago  he  was  voiding  urine  about  five  times  every  night.  He 
consulted  a  physician  who  used  a  catheter,  and  since  then  catheterization 
has  been  necessary,  voluntary  urination  being  impossible.  For  four 
months  the  patient  catheterized  himself  very  frequently  and  he  now  draws 
his  urine  every  two  hours. 

Pain. — No  note  made. 

Examination. — The  patient  is  emaciated  and  weak.  The  heart  and  lungs 
are  negative.    Abdomen  and  genitalia,  not  noted. 

Rectal. — The  prostate  is  greatly  enlarged,  about  the  size  of  a  small 
orange.  It  is  rough,  nodular,  and  very  hard.  The  right  lobe  is  larger 
than  the  left  and  presents  one  very  large  hard  prominent  nodule  which 
passes  toward  the  rectum.  The  induration  extends  upwards  towards  the 
region  of  the  seminal  vesicles  and  it  is  difficult  to  reach  the  upper  end 
of  the  prostate  with  the  finger. 

The  diagnosis  of  cancer  or  a  very  fibrous  prostate  was  made. 

Urinalysis. — Cloudy,  acid,  albumin,  pus  cells. 

Operation,  August  17,  1898. — Perineal  prostatectomy  with  preliminary 
suprapubic  cystotomy  (Alexander's  operation).  The  bladder  was  opened 
above  the  pubes  for  examination  and  assistance  in  pushing  down  the 
prostate  during  perineal  prostatectomy.  Examination  showed  no  median 
lobe  hypertrophy.  The  urethral  orifice  was  patent,  but  although  the 
prostatic  lobes  did  not  project  into  the  bladder  the  prostate  pushed  the 
anterior  wall  towards  the  bladder  cavity  and  there  was  a  bas-fond  behind 
it.  Perineal  prostatectomy  was  performed  with  the  patient  in  the  lithotomy 
position,  through  an  incision  which  started  in  the  median  line  and  extended 
to  the  right  side  of  the  anus.  The  levator  ani  muscles  were  separated 
and  the  base   of  the  prostate  exposed.     It  was  hard,   nodular,   and  the 


An  Operation  for  Cancer  of  Prostate.  555 

induration  extended  into  the  right  seminal  vesicle  whicli  was  enlarged 
and  closely  adherent  to  the  upper  end  of  the  prostate.  The  prostatic 
lobes  were  divided  on  each  side  parallel  to  the  urethra  which  contained 
a  catheter  and  leaving  a  block  of  tissue  adjacent  to  the  urethra.  The 
tissue  was  so  hard  that  it  was  necessary  to  use  the  scissors,  and  gave 
the  impression  of  scirrhous  cancer.  The  right  seminal  vesicle  was  excised 
partially  with  the  right  lateral  lobe.  A  small  tear  was  made  in  the 
prostatic  urethra.  The  wound  was  packed  with  gauze  and  the  bladder  was 
drained  through  a  catheter,  and  the  suprapubic  wound  was  closed.  The 
patient  was  considerably  shocked  by  the  operation  and  received  two 
infusions. 

Convalescence. — The  patient  reacted  fairly  well,  the  gauze  pack  was  re- 
moved at  the  end  of  24  hours  and  the  urethral  catheter  on  the  fifth  day. 
The  suprapubic  suture  of  the  bladder  did  not  leak,  and  the  gauze  was 
removed  from  the  prevesical  space  on  the  13th  day.  The  patient  did 
not  require  catheterization  after  the  operation,  but  urination  was  quite 
frequent.  On  September  25,  a  catheter  found  30  cc.  residual  urine  and  a 
bladder  capacity  of  130  cc.  On  December  17,  the  patient  was  discharged 
from  the  hospital.  A  catheter  showed  50  cc.  residual  urine  and  a  bladder 
capacity  of  300  cc.  There  was  a  small  perineal  fistula,  but  the  patient 
was  able  to  void  naturally  through  the  urethra  and  did  not  use  the 
catheter. 

August  5,  1899. — Letter.  The  patient  reports  that  he  is  unimproved  and 
that  he  has  to  use  the  catheter  regularly  as  before  operation. 

January  8,  1902. — Letter  from  wife.  "  My  husband  continued  to  use  the 
catheter  and  suffered  a  great  deal  of  pain.  The  perineal  fistula  never 
healed,  and  later  a  very  large  open  sore  appeared.  A  few  weeks  before  he 
died  the  bladder  ruptured  into  the  bowel,  and  the  urine  came  away  with  the 
stools.    He  became  very  drowsy  and  died  March  6,  1900." 

Pathological  report. — The  specimen  consists  of  the  prostate  gland  re- 
moved in  fragments.  Of  these  one  contains  a  patent  canal — perhaps  a 
seminal  vesicle.  The  glandular  portion  is  excessively  hard,  firm,  and 
resistant  to  pressure,  and  cuts  with  a  peculiar  sound  of  fibrous  tissue. 
There  can  be  no  stripping  of  capsule.  The  glandular  tissue  seeming  inti- 
mately associated  with  surrounding  structures.  On  section  the  tissue  is 
translucent,  but  not  homogeneous  as  lines  and  dote  can  be  made  out.  There 
is  nothing  expressed  oh  pressure,  but  a  clear  serous  fluid.  The  line  of 
demarkation  between  the  glandular  portion  and  the  surrounding  hemor- 
rhagic area  is  sharp,  but  no  separation  can  be  made  by  dissection.  The 
portion  containing  the  duct  or  canal,  shows  this  structure  as  what  appears 
to  be  the  posterior  edge  of  the  prostate. 

Microscopic  examination. — The  tissue  is  that  of  an  adenocarcinoma  with 
a  large  amount  of  stroma.  The  acini  show  a  great  deal  of  intraacinous  pro- 
liferation which  at  times  results  in  the  formation  of  small  alveoli  filled 
with  new  formed  acini  and  containing  comparatively  no  stroma.  Here 
and  there  the  epithelium  which  shows  involution  changes  characteristic 


556  Hugh  R.  Young. 

of  carcinoma  is  breaking  through  these  alveolar  walls,  and   infiltrating 
the  surrounding  stroma. 

This  carcinoma  might  be  termed  a  tubular  form  of  adenocarcinoma. 

Case  9. — Moderate  enlargement  of  the  lateral  loies.  SuprapuMc  cystos- 
tomy  six  months  previously.  Perineal  prostatectomy.  Imperfect  result. 
Restoration  of  natural  urination,  lut  considerable  residuum  present.  Small 
area  of  cancer  discovered,  microscopically. 

No.  463.    J.  T.  Y.,  age  60,  married,  admitted  September  24,  1903. 

Complaint. — "  Prostatic  obstruction.     Suprapubic  urinary  fistula." 

Gtonorrhoea  in  1882,  was  cured  without  complication. 

Present  illness  began  two  years  ago  with  frequency  of  urination.  The 
course  of  the  disease  was  characterized  by  diflficulty  of  urination,  gradual 
increasing  frequency,  pain  near  the  end  of  the  penis  before  and  during 
urination.    No  hematuria. 

In  October,  1902,  he  had  typhoid  fever  and  had  to  be  catheterized  for 
some  time.  During  the  spring  of  1903,  urination  was  very  frequent  and 
difficult,  and  his  physician  performed  suprapubic  cystostomy. 

S.  P. — The  patient  is  wearing  a  Bloodgood  bag.  He  suffers  considerably 
from  pain  in  the  bladder.    Is  unable  to  void  urine. 

Sexual  powers. — Good. 

Examination. — The  patient  is  a  strong  looking  man  with  lips  and  mucous 
membrane  of  good  color.  Chest  is  negative.  A  suprapubic  fistula  is 
present  in  which  the  patient  wears  a  tube  connected  with  a  Bloodgood  bag. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth,  rather  hard 
in  consistence.  The  median  furrow  is  shallow,  but  the  notch  is  quite  deep. 
The  seminal  vesicles  cannot  be  palpated,  but  the  lateral  lobes  extend 
upward  and  outward  into  the  region  of  the  vesicles  and  are  quite  closely 
adherent  to  the  pelvic  walls. 

Cystoscopic. — ^The  cystoscope  is  introduced  through  the  suprapubic 
wound,  and  shows  two  fairly  large  intravesical  lateral  lobes  with  a  deep 
sulcus  anteriorly  and  posteriorly  and  a  greatly  flattened  urethra  between 
them.  Posteriorly  there  is  a  very  slight  median  bar  of  mucous  membrane 
which  connects  the  two  lobes.  Another  cystoscope  was  inserted  through 
the  urethra  and  showed  the  same  as  the  suprapubic  cystoscope  (see 
detailed  description  in  article  on  cystoscopy  of  the  prostate.  Case  II). 
With  finger  in  rectum  and  cystoscope  in  urethra  there  is  very  little  median 
enlargement  found. 

Operation,  Octoher  4,  1903. — In  Lynchburg,  Va.  Chloroform.  Perineal 
prostatectomy  by  the  usual  technique.  The  lateral  lobes  were  surprisingly 
small  and  were  removed  with  difficulty  owing  to  adhesions.  At  the 
end  of  the  operation  the  lateral  cavity  was  carefully  examined  with  the 
finger  and  no  enlargement  was  found.  The  blade  of  the  tractor  in  the 
bladder  could  be  easily  felt  with  only  a  thin  mucous  membrane  inter- 
vening. After  the  operation  a  finger  was  inserted  in  the  suprapubic 
wound  and  no  intravesical  enlargement  found.     The  wound  was  closed 


An  Operation  for  Cancer  of  Prostate.  557 

as  usual  with  double  drainage  tubes,  light  packs  for  the  lateral  cavities, 
and  a  large  suprapubic  drainage  tube.  He  stood  the  operation  well.  Con- 
tinuous irrigation  was  begun  on  return  to  room  and  his  doctor  was 
instructed  to  continue  the  irrigation  for  four  or  five  days,  to  withdraw  the 
perineal  packing  partly  on  the  third  day  and  completely  on  the  fifth 
and  to  remove  the  perineal  tubes  on  the  seventh  day. 

October  12,  1903. — The  patient  has  done  beautifully  and  has  not  had  an 
untoward  symptom.  The  packing  and  perineal  tubes  were  removed  on  the 
fifth  day  and  since  then  all  of  the  urine  has  come  through  the  suprapubic 
opening  in  which  he  is  still  wearing  a  tube.  The  perineal  wound  is 
healing  rapidly  and  there  has  been  no  leakage  since  the  perineal  tubes 
were  removed. 

December  15,  1903. — "  All  the  wounds  have  healed  and  I  urinate  through 
the  penis,  but  it  is  slow.  I  am  improving,  however,  and  feel  infinitely 
better  than  I  did  before  operation." 

January  20,  1904- — "  I  void  urine  about  every  two  and  one-half  hours 
during  the  day,  but  only  once  and  sometimes  twice  during  the  night. 
Urination  is  neither  easy  or  satisfactory,  is  very  slow  in  starting,  and  I 
have  to  make  three  or  four  attempts  in  the  morning  before  I  can  empty 
my  bladder.    My  general  health  is  good." 

May  20,  190If. — "  Yesterday  I  held  urine  from  11  a.  m.  to  4.30  p.  m.  and 
voided  half  a  pint,  but  urination  is  not  entirely  satisfactory.  I  have  had 
no   erections." 

February  1,  1905. — "  I  void  urine  naturally  but  not  satisfactorily,  two  or 
three  times  at  night,  sometimes  15  times  during  the  day,  general  about 
one-quarter  of  a  pint  at  a  time,  sometimes  not  more  than  a  table- 
spoonful.  I  have  a  burning  sensation  before  urinating.  My  general  health 
is  good." 

July  18,  1905. — The  patient  feels  well,  but  generally  gets  up  every  two 
or  three  hours  to  urinate  at  night,  and  sometimes  has  considerable 
hesitation,  at  other  times  urine  passes  freely,  and  he  may  be  able  to  retain 
it  for  five  hours.  He  has  had  no  erections,  but  two  weeks  ago  had  a 
profuse  nocturnal  emission. 
Examination. — Both  wounds  are  firmly  healed. 

Rectal. — In  the  region  of  the  prostate  is  a  hard  cicatrix  which  is  smaller 
than  the  ordinary  prostate.  Nothing  resembling  prostatic  enlargement 
is  to  be  felt  and  the  bladder  above  is  soft.  A  catheter  passes  with  ease 
and  finds  650  cc.  residual  urine.  The  patient  had  just  voided  100  cc. 
The  cystoscope  shows  two  intravesical  lobular  outgrowths  in  the  lateral 
lobes  with  a  deep  sulcus  anteriorly  and  posteriorly.  There  is  no  median 
posterior  enlargement,  but  a  small  fold  of  mucous  membrane  joins  the  two 
lateral  lobes.  These  lateral  lobules  are  apparently  small,  but  come 
together  like  valves  as  seen  by  moving  the  cystoscope  up  and  down. 
The  bladder  is  only  slightly  trabeculated.  There  is  no  calculus  present. 
With  finger  in  rectum  and  cystoscope  in  urethra  there  is  no  increase  in 
median  portion  shown. 


558  Hugh  H.  Young. 

Remark. — A  study  of  the  history  of  this  case  shows:  That  the  intra- 
vesically  projecting  lateral  lobes  were  not  completely  removed  at  operation. 
Urination  has  never  been  free  and  satisfactory  as  is  usually  the  case, 
and  the  cystoscope  now  shows  much  the  same  picture  in  the  bladder  as 
before  operation,  and  the  catheter  finds  650  cc.  residual  urine.  From  sub- 
sequent experience  it  seems  evident  that  when  traction  was  made  with  the 
prostatic  tractor  the  blades  slipped  beneath  the  prominent  lateral  lobes, 
there  being  no  median  lobe  present  to  hold  up  the  shaft  of  the  instru- 
ment. The  lobes  removed  at  operation  were  smaller  than  was  expected, 
and  examination  now  shows  that  these  represented  only  that  part  of 
each  lobe  which  presented  rectally,  and  the  intravesically  projecting  lobes 
which  were  above  the  blades  of  the  tractor  were  not  removed.  In  several 
cases  which  I  have  had  of  late  this  would  have  happened  had  I  not 
been  careful  to  engage  and  draw  down  the  intravesical  portion  after  re- 
moval of  the  rectally  presenting  portion.  This  was  not  done  in  this  case. 
A  second  operation  was  advised  with  the  view  of  enucleating  the  remain- 
ing lobule.    Patient  refused  operation. 

November  30,  1905. — Letter.  "  I  am  not  cured  but  very  much  benefited. 
I  void  urine  naturally  but  not  always  satisfactorily,  two  or  three  times 
at  night  and  from  eight  to  twelve  times  during  the  day,  about  one-quarter 
of  a  pint  at  a  time.  I  suffer  no  pain,  have  not  had  erections.  My  general 
health  is  good." 

Pathological  examination. — The  specimen,  G.  U.  232,  consists  of  two  lobes, 
the  right  and  left  lateral  which  have  been  removed  each  in  one  piece, 
and  measure  about  2x3x3  cm.  in  size  and  weigh  about  G.  12.  The  sur- 
faces are  lobulated,  the  consistency  elastic,  and  on  section  the  tissue  pre- 
sents the  usual  appearance  of  benign  hypertrophy. 

Microscopic  examination. — Several  sections  have  been  made,  and,  with 
one  exception,  show  only  a  benign  glandular  hypertrophy.  The  acini  are 
dilated;  there  is  much  intraacinous  budding,  and  the  epithelium  has 
formed  rugae  with  cells  two  or  more  layers  deep.  The  stroma  is  slight 
in  amount,  and  mostly  muscle.  Numerous  areas  of  chronic  prostatitis 
are  seen.  A  section  from  this  prostate  presents  a  most  interesting 
picture.  The  prostate  is  of  a  benign  type  apparently  except  in  one 
small,  somewhat  spherical  area  of  minute  size  (see  Fig.  16).  The  acini 
within  this  area  are  small,  irregular  in  shape,  rather  closely  set  together, 
and  the  picture  immediately  strikes  one  as  being  atypical.  The  epithelium 
lining  these  small  compact  acini  is  mostly  of  a  cylindrical  type,  and 
usually  consists  of  a  single  layer.  Occasionally  the  small  acini  are  lined  by 
a  rather  cuboidal  type  of  epithelium.  The  nuclei  vary  some  in  size,  some- 
times being  rather  small  and  round,  at  other  times  fairly  large  and 
irregular.  Not  infrequently  one  sees  a  solid  tube  of  epithelium.  The 
epithelium  apparently  at  no  definite  point  shows  a  definite  breaking 
through  of  the  acinous  wall  to  infiltrate  the  surrounding  stroma.  Many 
of  the  acini  have  apparently  no  basement  membrane,  and  the  epithelium 
seems  to  line  simply  an  open  space.     About  the  periphery  of  this  small 


An  Operation  for  Cancer  of  Prostate.  559 

lobule  these  atypical  acini  are  infiltrating  irregularly  the  surrounding 
stroma.  The  stroma  between  the  acini  of  this  nodule  is  rather  small  in 
amount  and  consists  of  slender  interlacing  bands  rather  loose  and 
cellular  in  character.  The  diagnosis  of  malignancy  within  this  small 
limited  area  seems  warranted.  The  atypical  acini,  atypical  in  shape  and 
the  character  of  their  epithelium,  and  the  definite  infiltration  of  the 
surrounding  stroma  seem  to  point  definitely  towards  malignancy. 

Case  10. — Small  indurated  prostate  carcinoma.  No  intravesical  lohes. 
Complete  retention  of  urine.  Double  kidney  infection,  uremia,  fever. 
Perineal  prostatectomy.  Restoration  of  natural  but  somewhat  frequent 
urination  followed  tiventy-six  months  after  operation. 

No.  576.    D.  C,  age  72,  admitted  March  15,  1904. 

Complaint. — "  Complete  retention  of  urine." 

No  history  of  gonorrhoea. 

Present  illness  began  about  three  years  ago  with  difficulty  and  increased 
frequency  of  urination,  which  gradually  increased.  During  the  last  four 
or  five  months  the  patient  has  had  to  void  every  half  hour  during  the  night, 
but  there  has  been  no  pain  until  recently.  About  ten  days  ago  he  was 
unable  to  urinate  and  a  physician  attempted  to  catheterize  him,  but 
without  success.  He  then  began  to  void  small  amounts  and  was  cathet- 
erized  the  next  day,  three  pints  of  urine  being  evacuated.  During  the 
next  week  he  voided  urine  very  frequently  and  suffered  a  great  deal  of 
pain.  On  March  12,  he  was  again  catheterized  with  difficulty,  1500  cc. 
urine  being  withdrawn.  He  was  not  catheterized  again  until  40  hours 
later  (although  he  had  voided  very  little),  and  this  was  after  admission 
to  the  Johns  Hopkins  Hospital.  One  week  ago  he  had  a  severe  attack  of 
pain  in  the  region  of  the  left  kidney  radiating  thence  toward  the 
bladder  accompanied  by  vomiting  and  fever.  This  has  continued  up 
to  the  present  time. 

S.  P. — The  patient  has  complete  retention  of  urine,  great  pain  in  the 
region  of  the  bladder.  His  physician  has  been  unable  to  catheterize 
him. 

Sexual  poivers. — No  note  made. 

Examination. — The  patient  is  a  very  thin  weak  old  man.  The  chest  is 
thin  and  flat,  expansion  very  poor.  Both  lungs  clear.  The  heart  sounds 
are  clear,  but  the  second  aortic  is  accentuated.  The  pulse  is  68,  regular 
and  of  good  volume,  and  fair  tension,  but  the  arteries  are  moderately 
sclerotic.  The  abdomen  is  distended  in  the  lower  part,  and  there  is  slight 
tenderness  on  deep  palpation  over  the  whole  abdomen.  In  the  region  of 
the  left  kidney  there  is  marked  tenderness  with  resistance  and  voluntary 
muscle  spasm  preventing  deep  palpation.  The  bladder  is  markedly  dis- 
tended and  very  tender.    Genitalia  negative. 

A  silver  catheter  passes  with  ease  and  finds  500  cc.  of  pale  clear  urine. 

Rectal. — The  prostate  is  slightly  enlarged,  hard,  smooth.  The  seminal 
vesicles  are  palpable  and  indurated. 


560  Hugh  H.  Young. 

Urinalysis. — March  15.  Pale,  1005,  slightly  acid,  no  sugar,  albumin  a 
trace. 

Microscopically  pus  cells,  epithelium  and  bacteria. 

Preliminary  treatment. — March  19.  The  patient  has  been  catheterized 
three  times  a  day.  Residual  urine  is  about  540  cc.  The  patient  is  weak 
and  takes  his  nourishment  poorly.  He  is  irrational  and  there  is  still  a 
marked  tenderness  in  the  region  of  the  left  kidney.  Temperature  sub- 
normal, to-day  96°,  pulse  64. 

March  20,  1904. — The  patient  was  delirous  and  has  had  hiccoughing  for 
12  hours.  He  seems  very  weak.  Temperature  still  subnormal.  Infused 
with  850  cc.  salt  solution. 

March  21,  1904. — Condition  of  patient  continues  bad.  A  retained  catheter 
is  supplied  for  continuous  drainage.  Water  in  abundance  by  mouth, 
rectum,  and  infusions. 


Fig.   is. — Cystoscopic  chart  before  operation.   Case  No.   10. 

March  31. — For  several  days  the  patient  continued  irrational  with  nausea 
and  vomiting,  pain  in  the  region  of  the  left  kidney  and  definite  evidence 
of  uremia.  Under  continuous  drainage  and  active  hydrotherapy  his 
condition  has  gradually  improved.  The  specific  gravity  of  the  urine  has 
increased  from  1005  to  1014.  The  amount  voided  being  about  the  same, 
varying  from  1600  to  2400  cc.  The  patient  is  now  out  of  bed,  eats  and 
sleeps  well  and  is  now  much  brighter  and  stronger. 

Cystoscopy,  April  4. — The  bladder  has  become  considerably  contracted, 
retains  very  little  fluid  making  cystoscopy  diflicult.  The  cystoscope 
shows  a  definite  circular  enlargement  around  the  entire  orifice  as  shown 
in  the  chart.  Fig.  18.  There  are  no  definite  lobes  and  no  sulci,  but  the 
entire  orifice  is  constricted  by  a  circular  ring  of  small  size.  The  surface 
is  a  little  irregular.  The  bladder  is  markedly  inflamed,  no  stone  present. 
With  flnger  in  rectum  and  cystoscope  in  urethra  there  is  a  definite  increase 
in  the  median  portion. 

April  6,  1904- — Patient  had  a  sudden  rise  of  temperature  to  102.8°  and 
he  became  slightly  irrational.  The  amount  of  urine  voided  is  good, 
about  2500  cc.  in  amount,  an  infusion  was  given  and  he  now  seems 
brighter. 


An  Operation  for  Cancer  of  Prostate.  561 

April  IJf,  1904- — During  the  past  week  there  has  been  a  fever  reaching 
101°  daily.  He  is  irrational  at  times  and  very  weak,  but  is  up  in  a  wheel 
chair.    Water  is  forced  and  occasionally  he  has  been  infused. 

April  21,  1904- — For  four  days  the  patient's  temperature  was  almost 
normal.  During  the  past  two  days  it  has  risen  again  to  101°.  The  general 
condition  is  weak  but  somewhat  better  than  previously.  The  bladder  has 
become  much  contracted  and  holds  only  30  cc.  The  patient  seems  to  have 
reached  a  stand  still  and  operation  is  decided  on  as  necessary  to  prevent 
a  decline. 

Operation,  April  22,  1904. — Spinal  anesthesia.  Perineal  prostatectomy 
by  the  usual  technique.  One-third  of  a  grain  of  cocaine  was  dissolved  in 
the  spinal  fluid  and  produced  excellent  anesthesia.  The  lateral  lobes  were 
very  little  larger  than  normal,  were  markedly  adherent,  had  to  be  dis- 
sected free  from  capsule  and  urethra  and  the  left  was  removed  in  two 
pieces.  No  median  mass  could  be  engaged  with  the  tractor  which  was 
therefore  removed  and  a  finger  inserted  into  the  bladder.  The  entire 
prostatic  urethra  was  found  contracted  so  that  it  was  difficult  to  introduce 
the  index  finger  and  in  so  doing  the  right  lateral  wall  of  the  urethra  was 
split  open.  Examination  showed  no  remaining  prostatic  obstruction  around 
the  prostatic  orifice  which  was  surrounded  by  a  fairly  tight  ring.  After 
thorough  dilatation  of  this  it  was  not  though  advisable  to  remove  the 
median  portion  of  the  prostate  which  did  not  seem  at  all  enlarged.  The 
wound  was  closed  as  usual  with  double  tube  drainage  and  light  packs  for 
the  lateral  cavities.  An  infusion  was  given  at  the  beginning  of  the 
operation  and  continuous  irrigation  on  return  to  the  ward.  The  patient 
stood  the  operation  well.    Pulse  at  the  end  60. 

Convalescence. — The  patient  reacted  well,  but  the  temperature  rose  to 
101.7°  on  the  night  after  the  operation  and  on  the  fourth  day  reached 
103.3°.  After  one  week  it  reached  normal  and  remained  practically  so. 
The  gauze  was  removed  on  the  third  day  and  the  tubes  on  the  fourth  day. 
He  drank  water  well,  but  was  infused  on  the  sixth  day.  He  was  out  of  bed 
during  the  first  week  and  walked  during  the  second  week.  Urine  did  not 
fiow  through  the  urethra  until  the  22d  day.  He  had  no  complications  after 
the  operation  and  left  the  hospital  on  the  37th  day.  The  fistula  was 
healed  (34th  day),  and  he  voided  urine  naturally  without  pain  and  at 
frequent  intervals. 

June  4>  1904- — The  patient  complains  of  frequency  of  urination,  the 
interval  being  one  and  one-half  to  two  hours.  Silver  catheter  passes 
without  meeting  obstruction  and  finds  20  cc.  residual  urine.  The  bladder 
is  contracted  and  holds  only  150  cc.  on  forced  distention.  The  patient  is 
advised  to  drink  water  in  abundance  and  to  hold  urine  as  long  as  possible 
in  order  to  distend  the  bladder. 

June  28,  1904- — During  the  past  week  the  bladder  has  been  dilated  by 
hydraulic  pressure  once  daily,  the  capacity  is  now  270  cc.  Under  this 
treatment  the  fistula  reopened  but  it  has  now  been  closed  for  one  week. 

November  11,  1904. — The  bladder  capacity  on  forced  distention  was  240 
cc.     Urination  easy,  but  frequent. 


562 


Hugh  H.  Young. 


January  13,  1905. — Letter.  "  I  void  urine  naturally  without  pain  except 
a  slight  one  at  the  beginning  of  urination,  three  or  four  times  at  night 
and  every  two  hours  during  the  day  and  about  four  ounces  at  a  time. 
My  general  health  is  fairly  good." 

November  SO,  1905. — Letter.  "  I  void  urine  naturally  three  or  four  times 
during  the  night  and  every  two  hours  during  the  day,  four  or  five  ounces 
at  a  time.  The  wound  has  remained  healed.  I  suffer  very  little  pain. 
Do  not  have  erections.  My  general  health  is  fairly  good.  I  have  gained 
in  weight  and  consider  myself  cured." 

May  12, 1906. — Patient  reports  for  examination.  He  voids  urine  naturally 
with  a  fairly  good  stream  and  without  pain.  Urination  is  more  frequent 
than  normal,  the  interval  being  generally  about  two  hours,  but  sometimes 


Fig.  19. — Cystoscopy  one  year  after  perineal  prostatectomy,  Case  No.  10. 


he  is  unable  to  go  more  than  one  hour,  and  when  the  desire  to  urinate 
comes  on,  it  is  very  imperative  and  he  must  void  at  once — there  is  no 
incontinence.  He  gets  up  about  three  times  during  the  night.  There  has 
been  no  hematuria,  no  calculus,  no  pain  in  back,  hips,  legs,  groins,  or 
testicles.  He  has  not  lost  weight,  and  his  general  health  is  good.  He  is 
engaged  in  light  occupation. 

Examination. — The  patient  looks  well,  lips  of  good  color.  The  epi- 
trochlear  and  cervical  glands  are  not  palpable.  In  the  right  groin  there 
are  several  shot-like  indurated  glands. 

Rectal. — In  the  region  of  the  prostate  is  a  transverse  mass  somewhat 
irregular  and  nodular,  in  places  soft,  in  others  quite  hard,  this  extends  up 
on  each  side  into  the  region  of  each  seminal  vesicle  and  there  is  also 
induration  between  the  vesicles,  the  upper  edge  of  which  presents  a 
broad  concaved  border  which  extends  outward  towards  the  pelvis  on  each 
side.  In  the  region  of  the  left  vesicle  the  induration  is  most  marked  and 
it  extends  along  the  pelvis  beyond  the  reach  of  the  finger.  It  is  distinctly 
nodular  and  quite  hard,  no  enlarged  glands  are  felt  on  that  side.     On  the 


An  Operation  for  Cancer  of  Prostate.  563 

right  side  near  the  pelvic  wall  one  indurated  gland  is  felt,  but  it  is 
difficult  to  distinguish  from  the  nodular  vesical  adjacent  to  it.  The  in- 
duration of  the  prostate  extends  down  and  involves  the  membranous 
urethra,  and  is  very  close  to  the  skin  of  the  perineum.  The  bulb  of  the 
urethra  is  not  involved. 

Cystoscopic. — A  small  rubber  catheter  passes  with  ease  and  finds  35  cc. 
residual  urine,  bladder  capacity  260  cc,  on  forced  distention.  The  cysto- 
scope  is  firmly  grasped  in  the  urethra,  but  enters  after  some  pressure 
Examination  of  the  prostatic  orifice  shows  a  small  induration  in  front 
and  on  each  side  as  shown  in  accompanying  chart.  Fig.  19.  In  the  median 
portion  of  the  prostate  there  is  an  irregular  enlargement  which  is  con- 
tinuous with  the  rounded  elevation  of  the  trigone  on  both  sides,  this 
elevation  extends  back  and  involves  the  region  around  the  ureteral  orifices. 
On  the  right  side  the  ureteral  orifice  is  seen  on  the  summit  of  a  globular 
projection.  On  the  left  side  the  ureteral  orifice  cannot  be  seen,  but  it 
is  probably  on  a  similar  projection  adjacent  to  a  diverticulum  which  is 
shown.  The  middle  portion  of  the  trigone  is  not  so  much  involved  as  the 
lateral  portion.  The  mucous  membrane  is  everywhere  smooth  and  there 
is  no  villous  tumor  or  ulceration.  With  finger  in  rectum  and  cystoscope 
in  urethra  it  is  impossible  to  feel  the  beak  of  the  instrument  there  being 
a  considerable  mass  between. 

Urine  acid,  1013,  trace  of  albumin,  considerable  pus,  many  bacilli. 

Pathological  examination. — The  specimen,  G.  U.  77,  consists  of  three 
pieces  of  prostatic  tissue,  two  of  which  represent  the  right  lobe  and  one  the 
left,  total  weight  is  only  8-G.  Consistency  of  the  tissue  is  very  hard,  and 
was  adherent  to  the  capsule.  On  cross  section  the  tissue  is  not  lobulated, 
and  composed  of  spheroidal  bodies  as  one  sees  in  the  usual  benign  hyper- 
trophy. The  surface  is  somewhat  granular  and  numerous  fine  yellow 
points  are  seen  scattered  here  and  there  in  a  white  field.  The  prostatic 
ducts  are  not  visible,  and  one  gets  the  impression  of  a  very  dense  tissue. 
The  general  appearance  is  much  the  same  in  all  three  portions  of  the 
prostate  removed. 

Microscopic  examination. — The  carcinoma  presents  itself  in  the  form  of 
tubules  in  an  apparently  normal  looking  stroma.  These  tubules  evidently 
represent  acini  which  have  become  carcinomatous,  and  are  of  varying  sizes. 
The  tubules  are  lined  by  a  cylindrical  epithelium  which  is  very  pale 
staining  with  small  sometimes  good  sized  round  nuclei.  The  epithelium 
at  times  grows  out  in  strands  from  the  periphery  uniting  and  interlacing 
in  different  ways  so  that  irregular  shaped  open  spaces  are  formed.  (See 
Fig.  14.)  These  epithelial  strands  apparently  have  no  supporting  frame- 
work of  stroma.  In  other  tubules  the  epithelium  fills  the  entire  lumen  with 
cells  of  a  pavement  type  while  again  the  mass  of  irregular  shaped  clear 
cells  grows  out  from  one  point  of  the  periphery  to  the  lumen  of  the  tubule. 
The  tubules  are  for  the  most  part  separated  by  considerable  bands  of  nor- 
mal looking  fibro-muscular  stroma,  in  other  areas  they  are  fairly  closely 
aggregated.  The  epithelium  does  not  seem  to  be  of  a  malignant  type  and 
nowhere  does  it  seem  to  break  through  the  wall  of  the  tubule  and  infiltrate 


564  Hugh  H.  Young. 

the  surrounding  stroma.  In  a  section  obtained  from  one  portion  of  the 
prostate  a  myomatous  form  of  hypertrophy  was  encountered,  the  muscle 
occurs  in  large  bundles,  occasionally  atrophic  looking  acini  being  present 
in  the  myomatous  nodule  and  at  other  times  being  pressed  together  about 
the  periphery  of  the  myomatous  nodules.  The  picture,  however,  in  this 
myomatous  portion  is  not  always  a  malignant  one.  The  acini  seem  to  be 
those  normally  present  which  are  undergoing  compression  and  atrophic 
changes  as  a  result  of  the  myomatous  hpyerplasia,  but  in  other  portions 
(see  Fig.  15)  definite  nests  of  cancer  cells  are  seen.  That  the  picture  pre- 
sented by  the  tubular  adenomatous  form  of  growth  described  above  is  a 
malignant  one  is  demonstrated  beyond  doubt  by  the  finding  of  several 
nests  of  cancer  cells  in  the  lymphatic  spaces  of  several  nerve  sheaths  in 
the  periphery  of  the   prostate. 

Case  11. — Carcinoma  of  the  prostate.  Malignancy  suspected  at  opera- 
tion, but  radical  operation  not  attempted. 

J.  R.,  aged  78,  widowed,  admitted  June  26,  1905. 

Complaint. — "  Frequent  and  painful  micturition.     Catheterism." 

Gonorrhoea  40  years  ago. 

Present  illness  began  about  four  years  ago  with  frequency  of  urination. 
This  gradually  increased,  but  three  months  ago  urine  was  voided  about 
every  hour,  since  then  the  patient  has  used  a  catheter  four  times  a  day. 
Between  catheterizations  he  is  able  to  void  urine  with  considerable  strain- 
ing and  at  frequent  intervals.  No  hematuria,  no  gravel,  no  incontinence. 
Both   testicles    have    been    swollen. 

Sexual  powers. — Erections  have  been  absent  for  the  past  three  years. 

Examination. — The  patient  is  well  nourished,  strong  and  healthy  looking, 
with  lips  of  good  color.  The  pulse  is  regular  and  strong  and  only  mod- 
erately sclerotic.     The  heart,  lungs  and  abdomen  are  negative. 

Rectal. — The  prostate  is  moderately  enlarged,  round  and  smooth.  The 
right  lobe  is  the  larger,  and  is  slightly  indurated,  but  elastic  and  does 
not  extend  into  the  region  of  the  seminal  vesicle.  Several  indurated 
cords  run  upward  from  it  to  the  lateral  wall  of  the  pelvis.  The  left 
lobe  is  smaller,  softer,  and  there  are  no  indurated  cords.  The  seminal 
vesicles  are  not  palpable.  There  is  no  intervesicular  mass,  no  enlarged 
glands  and  the  rectal  mucosa  is  soft. 

Cystoscopic. — A  catheter  passes  with  ease  and  finds  250  cc.  residual 
urine.  The  bladder  is  irritable,  the  urethra  very  long.  The  cystoscope 
apparently  cannot  be  introduced  into  the  bladder.  The  field  is  dark  and 
it  is  impossible  to  see  anything.  A  silver  catheter  gives  a  grating  sound 
in  the  prostatic  urethra  which  suggests  calculus. 

Urinalysis. — No  note. 

Preliminary  treatment. — For  four  days  the  patient  was  catheterized  two 
or  three  times  a  day  and  from  200  to  300  cc.  residual  urine  being  obtained. 
He  voids  urine  in  small  amount  with  considerable  pain  and  vesical  spasm. 
Urotropin  and  water  in  abundance. 

Operation  June  30,  1905.— Ether.     Perineal  prostatectomy  by  the  usual 


An  Operation  for  Cancer  of  Prostate.  565 

technique.  The  posterior  surface  of  the  prostate  was  smooth,  globular, 
not  difficult  to  separate  from  the  rectum  and  felt  only  slightly  indurated. 
Examination  of  the  lateral  incisions  showed  a  benign  appearance.  The 
left  lateral  lobe,  a  portion  of  which  projected  well  up  into  the  bladder 
was  removed  in  three  pieces.  The  right  lateral  lobe  was  a  little  adherent 
at  the  upper  end  and  had  to  be  excised  with  scissors.  Examination  of 
this  portion  showed  a  large  oval,  firmly  encapsulated  lobule,  the  cut  surface 
of  which  was  deep  yellow  in  color,  homogeneous  and  finely  granular, 
cartilaginous  in  firmness.  The  rest  of  the  prostate  was  soft,  and  semi- 
translucent.  Examination  of  the  capsule  and  seminal  vesicle  at  the 
upper  end  of  the  right  lobe  showed  induration  and  a  portion  of  this  tissue 
was  excised  and  removed  with  scissors.  This  induration  extended  into 
the  median  portion  of  the  prostate,  and  it  was  thought  best  to  excise  the 
median  portion  along  with  the  ejaculatory  ducts  suburethrally.  No 
mucous  membrane  was  excised  but  the  urethra  was  torn.  Palpation  above 
the  prostate  failed  to  reveal  any  glands  or  definite  evidence  of  invasion. 
Although  the  operator  suspected  carcinoma  the  age  and  condition  of 
patient  prevented  a  radical  operation.  There  was  only  a  moderate  amount 
of  hemorrhage,  the  wound  was  closed  as  usual  with  double  tube  drainage 
and  light  packs  for  the  lateral  cavities.  Infusion  on  table,  continuous 
irrigation  on  return  to  the  ward.  Pulse  at  the  end  of  the  operation  was 
105.     Condition  good. 

Convalescence. — The  patient  reacted  well.  The  temperature  arose  to 
101.4°,  but  after  the  second  day  was  practically  normal. 

The  gauze  and  tubes  were  removed  at  the  end  of  24  hours,  there  was 
very  little  bleeding.  There  was  considerable  hiccough  on  the  night  after 
the  operation,  and  the  patient  was  slightly  irrational.  A  second  infusion 
was  given  on  the  second  night,  and  on  the  two  successive  nights.  The 
hiccough  persisted  for  a  week,  at  first  being  distressing,  but  later  only 
occasional.  He  was  treated  by  hydrotherapy,  liquid  diet,  and  purgatives. 
After  the  ninth  day  his  condition  improved  rapidly,  the  temperature 
remained  normal,  and  the  patient  was  up  daily  and  soon  began  to  walk. 
The  wound  healed  nicely,  urine  began  to  come  through  the  urethra  on 
the  seventh  day,  on  the  28th  day  only  a  pin-point  fistula  remained,  and 
he  was  able  to  retain  urine  for  several  hours.  He  was  discharged  on  the 
30th  day. 

March  14,  1906. — Patient  returns  for  examination.  He  says  his  general 
health  is  good  and  he  has  gained  15  pounds  in  weight.  The  perineal 
wound  has  remained  closed,  he  voids  urine  naturally  and  in  a  good  stream, 
there  is  no  incontinence.  He  rises  only  once  or  twice  at  night  to  void 
and  retains  urine  four  hours  during  the  day.  He  suffers  no  pain,  not 
even  a  burning.  He  has  had  no  erections  since  two  years  before  operation. 
He  considers  himself  cured.  The  patient  voided  160  cc.  slightly  cloudy 
acid  urine,  sp.  gr.  1010.  He  says  fistula  closed  one  week  before  leaving 
hospital. 

Patliological  report. — The  specimen,  G.  U.  179,  consists  of  four  pieces, 


566  Hugli  H.  Young. 

the  left  and  three  pieces  comprising  the  right  lateral.  On  gross  examina- 
tion the  left  lateral  presents  the  usual  picture  of  benign  hypertrophy,  and 
several  spheroids  are  present.  There  is  nothing  in  this  tissue  microscopi- 
cally which  suggests  carcinoma.  The  right  lateral,  however,  over  about 
%  of  its  area  presents  a  picture  entirely  different  from  the  benign  hyper- 
trophy. The  right  lobe  shows  rather  typical  glandular  hypertrophy  except 
in  an  area  occupying  %  of  the  upper  surface  where  the  tissue  is  very 
smooth  and  shiny,  homogeneous  and  of  a  peculiar  brownish  color.  This 
tissue  makes  up  a  lobule  of  its  own  and  seems  rather  definitely  demarcated 
from  the  normal  looking  tissue  below.  This  area  suggests  very  strongly 
carcinoma,  and  cuts  with  a  marked  gritty  sensation. 

Microscopic  examination. — Sections  from  the  left  lateral  lobe  show 
a  normal  adenomatous  type  of  hypertrophy,  although  occasionally  one 
sees  an  acinus  in  which  the  proliferation  is  rather  profuse  and  the 
epithelium  shows  slight  involution  changes.  Sections  from  the  malignant 
looking  area  show  an  adenocarcinoma.  The  alveoli  are  small,  at  times 
very  closely  set  with  comparatively  small  amount  of  stroma  and  in  other 
areas  the  stroma  and  acini  being  in  about  equal  amount.  The  acini  are 
extremely  irregular  in  shape,  and  nowhere  simulate  closely  normal  acini. 
At  times  strands  of  epithelium  infiltrating  in  the  stroma  are  seen.  Occa- 
sional small  limited  areas  in  which  the  growth  is  rather  scirrhus  in  type 
are  to  be  seen.  The  growth,  however,  is  practically  a  pure  adenocar- 
cinoma. 

Case  12. — Carcinoma  of  prostate,  membranous  urethra  and  right  seminal 
vesicle.  Stricture  of  urethra.  Complete  retention  of  urine.  Catheteriza- 
tion impossible.  Refused  to  go  to  hospital.  Emergency  perineal  prosta- 
tectomy for  drainage,  at  residence.  Later  operation  for  complete  excision 
refused.    Result  of  operation  good. 

No.  1102.     J.  E.  H.,  age  64,  married,  admitted  November  4,  1905. 

Complaint. — "  Acute  retention  of  urine." 

Gonorrhoea  in  his  youth,  no  sequelae. 

On  August  26,  1904,  and  February  16,  1905,  had  attacks  characterized 
by  frequent  desire  to  urinate.     At  other  times  felt  well. 

Present  illness  began  six  months  ago  with  a  sudden  severe  pain  which 
came  on  during  urination,  and  was  located  in  the  end  of  the  penis.  It 
lasted  one-half  hour.  Previous  to  this  urination  had  been  normal,  the 
stream  large,  no  hesitancy,  no  increased  frequency,  did  not  get  up  at 
night.  Since  the  attack  above  described  he  has  had  similar  seizures  at 
intervals  of  two  to  three  weeks.  The  pain  was  generally  located  in  the 
penis,  but  at  times  it  was  referred  to  the  hips  or  radiated  down  the  legs 
to  the  toes.  Micturition  has  been  markedly  increased,  difficult  and  the 
amount  voided  small.  There  has  been  no  hematuria.  His  general  health 
has  been  good  and  there  has  been  no  loss  in  weight.  Yesterday  for  the 
first  time  complete  retention  of  urine  came  on.  His  physician  was  called 
in  this  morning  and  made  several  attempts  to  catheterize  him  without 
success.     I  was  then  consulted,  found  the  patient  suffering  greatly  from 


An  Operation  for  Cancer  of  Prostate.  567 

an  overdistended  bladder  which  reached  almost  to  the  umbilicus.  All 
attempts  to  pass  instruments  into  the  bladder  were  unsuccessful.  Various 
catheters  and  filiforms  were  used  without  success,  owing  to  an  obstruction 
about  seven  inches  from  the  meatus,  and  apparently  located  at  the  apex 
of  the  prostate.  With  the  finger  in  rectum  the  catheter  was  found  to 
stop  at  a  point  in  the  membranous  urethra. 

Rectal  examination  showed  a  prostate  which  was  slightly  enlarged  in 
both  lateral  lobes.  The  surface  was  somewhat  irregular,  very  hard,  and 
there  was  a  slight  mass  of  induration  about  1  cm.  wide  at  the  base  of 
the  right  seminal  vesicle  continuous  with  the  upper  end  of  the  prostate, 
and  also  occupying  slightly  the  notch  in  the  median  line.  Above  that 
the  seipinal  vesicle  was  negative  on  both  sides.  The  membranous  urethra 
was  enlarged,  hard,  and  there  was  a  peculiar  prominent  prolongation  of 
the  prostatic  induration  which  was  closely  attached  to  the  membranous 
urethra  on  the  right  side,  had  an  irregular  surface  and  was  extremely 
hard.  The  rectal  mucosa  was  soft  and  no  enlarged  glands  were  to  be  felt. 
The  patient  was  advised  to  go  to  the  hospital,  but  refused.  The  diagnosis 
was  not  positive.  The  stricture  seemed  to  be  in  the  region  of  the  mem- 
branous urethra,  and  it  was  thought  possible  that  the  process  was  of  a 
chronic  inflammatory  character,  though  the  possibility  of  malignancy  was 
suspected.  After  consultation  with  his  physician  and  family  it  was  thought 
best  to  provide  perineal  drainage  after  division  of  the  stricture,  and  at 
the  same  time  to  enucleate  the  lateral  lobes  of  the  prostate.  The  general 
condition  of  the  patient  was  excellent — there  has  been  no  loss  of  weight. 

Operation  November  4,  1905. — Ether.  At  home  of  patient.  Perineal 
prostatectomy  by  the  usual  technique.  The  membranous  urethra  and  apex 
of  the  prostate  were  exposed  as  usual.  The  rectum  was  very  adherent  to 
urethra  and  prostate,  and  had  to  be  dissected  free.  The  posterior  surface 
of  the  prostate  was  very  little  larger  than  normal,  slightly  rough  and 
very  hard.  Continuous  with  the  apex  of  the  prostate,  and  extending 
somewhat  to  the  left  was  a  prominent  mass  of  induration  closely  adherent 
to  the  membranous  urethra,  and  about  1%  cm.  long  by  1  cm.  wide.  The 
surface  was  very  irregular,  and  so  intimately  adherent  to  the  levator  ani 
that  dissection  was  necessary  to  free  it.  The  rest  of  the  membranous 
urethra  was  thickened  and  hard,  but  presented  much  the  appearance  of 
an  ordinary  stricture.  Owing  to  the  inability  to  pass  an  instrument 
urethrotomy  was  performed  without  a  guide.  The  lumen  of  the  mem- 
branous urethra  was  extremely  small  and  the  strictured  condition  extended 
into  the  prostatic  urethra  so  that  it  was  necessary  to  pass  a  filiform  and 
forcibly  dilate  the  prostatic  urethra  before  the  tractor  could  be  introduced. 
Through  the  usual  bilateral  longitudinal  incisions,  the  lateral  lobes  of 
the  prostate  were  excised.  They  were  markedly  adherent  to  the  urethra, 
capsule  and  bladder  and  the  scissors  had  to  be  freely  used.  Examination 
of  the  tissue  removed  showed  marked  induration,  a  cut  surface  of  almost 
homogenous  appearance,  no  evident  dots  and  lines  of  softer  material,  and 
the  appearance  of  a  very  fibrous  prostatitis.  The  surface  was  somewhat 
Vol.  XIV.— 39. 


568  Hugh  H.  Young. 

gritty  when  scraped  with  the  knife,  but  all  present  agreed  that  the 
appearance  was  not  suflBciently  suggestive  of  carcinoma  to  warrant  the 
radical  operation.  There  was  apparently  no  middle  lobe  present  and 
the  median  portion  of  the  prostate  was  not  removed,  the  urethra  and 
ejaculatory  ducts  were  preserved  intact.  The  mass  of  supposed  scar 
tissue  around  the  membranous  urethra  was  excised.  Double  tube  drain- 
age and  light  packs  for  the  lateral  cavities  was  provided,  and  the  wound 
closed  as  usual. 

Convalescence. — The  patient  suffered  greatly  from  pain  in  the  wound 
and  bladder  and  difficulty  of  urination.  These  symptoms  persisted,  and 
at  the  end  of  a  week  a  catheter  was  passed  and  showed  considerable 
residual  urine.  An  operation  was  decided  upon  for  two  reasons,  viz.: 
To  remove  an  obstructing  median  bar,  which  was  undoubtedly  present, 
and  to  obtain  additional  tissue  for  microscopic  examination,  the  specimen 
removed  having  been  lost  by  the  nurse. 

Second  operation  November  12,  1905. — The  wound  was  reopened  and  the 
prostate  exposed  with  the  posterior  retractor.  The  floor  of  the  urethra, 
the  median  ejaculatory  bridge,  median  portion  of  the  prostate,  and  a 
portion  of  the  neck  of  the  bladder  on  the  left  side  was  excised,  leaving 
a  large  opening  into  the  bladder.  Examination  with  the  finger  showed 
no  remaining  prostatic  enlargement,  no  intravesical  tumor,  no  ulcer. 
Examination  of  the  specimen  removed  showed  that  the  base  of  the  right 
seminal  vesicle  had  been  removed.  Microscopic  examination  showed  carci- 
mona.  Radical  operation  was  proposed  and  absolutely  refused  by  the 
family. 

Convalescence. — The  patient  reacted  well  from  the  operation,  was  very 
much  more  comfortable.  The  urine  escaped  through  the  perineal  wound. 
The  gauze  and  tubes  were  removed  within  two  days,  and  the  perineal 
wound  closed  finally  on  the  15th  day.  Interval  urination  was  at  once 
established,  and  the  intervals  between  urinations  gradually  increased.  On 
January  8,  1906,  the  patient  started  from  New  York  to  the  West  Indies. 

March  3,  1906. — The  patient  voids  with  ease  at  intervals  of  two  hours 
and  only  gets  up  once  at  night  to  urinate.  Occasionally  he  has  a  slight 
dull  pain  in  the  deep  urethra,  and  constantly  a  dull  pain  in  the  anterior 
portion  of  the  right  thigh.     No  pain  in  back,  perineum  or  rectum. 

Examination. — The  patient  looks  well  and  has  gained  in  weight.  The 
urine  is  clear,  and  microscopically  negative. 

Rectal. — In  the  region  of  the  prostate  an  indurated  mass  about  4  cm. 
wide  and  3  cm.  long  is  palpable.  The  rectum  is  adherent  to  it  and  is 
distinctly  rough  though  not  ulcerated.  An  indurated  mass  extends  up- 
ward and  outward  from  the  upper  portion  of  the  right  lobe  of  the  prostate 
for  a  distance  of  3  cm.  It  is  about  the  size  of  the  little  finger,  surface 
is  smooth,  and  the  upper  end  is  sharply  defined.  No  enlarged  glands  are 
to  be  felt,  and  the  region  of  the  left  seminal  vesicle  is  negative.  The 
perineal  wound  is  firmly  closed. 

April  4,  1906. — The  patient  can  retain  urine  from  two  to  three  hours. 


An  Operation  for  Cancer  of  Prostate.  569 

Some  nights  does  not  get  up  at  all.  Last  night  had  to  get  up  every  hour 
to  urinate;  urination  difficult,  came  in  drops  and  was  accompanied  by 
severe  pain  in  the  lower  abdomen.    No  pain  to-day  and  is  voiding  well. 

Examination. — Urine  is  clear,  no  infection  present.  The  patient  looks 
well. 

April  5,  1906.— The  patient  enjoys  good  health.  Voids  urine  freely,  often 
only  once  at  night.  He  suffers  very  little  pain  and  complains  most  of 
a  disagreeable  tickling  sensation  in  the  urethra. 

Pathological  examination. — The  specimen,  G.  U.  195,  consists  of  several 
pieces  of  prostate  and  a  portion  of  the  lower  end  of  a,  seminal  vesicle. 
On  gross  examination  it  is  fibrous  and  dense  and  areas  suggesting  the 
presence  of  epithelium  are  only  indistinctly  made  out.  On  microscopic 
examination  there  are  areas  usually  in  the  neighborhood  of  glands  of  the 
prostate,  but  also  near  the  seminal  vesicles  which  are  rich  in  cells. 
These  cells  are  partly  derived  from  connective  tissue  cells,  but  others 
occur  in  strands  and  nests  and  app'arently  are  of  epithelial  origin.  These 
masses  of  epithelial  cells  arranged  in  alveoli  are  growing  irregularly  and 
lawlessly  in  the  cellular  connective  tissue.  These  areas  occur  in  several 
scattered  patches  in  the  section,  but  especially  in  close  association  with 
the  glands.  The  stroma  in  relation  to  the  alveoli  is  fairly  abundant  ana 
occasionally  nuclear  figures  can  be  detected. 

Diagnosis. — Carcinoma,  simplex  scirrhus  type. 

Case  13. — Carcinoma  of  prostate  and  seminal  vesicles.  Catheter  life 
advised  but  refused.    Perineal  prostatectomy  to  relieve  obstruction.    Death, 

S.  No.  18897.     O.  H.  D.,  76,  married,  admitted  March  17,  1906. 

Complaint — ■"  Enlarged   prostate." 

No  history  of  venereal  diseases.  Ten  years  ago  had  a  fistula  in  ano 
for  which  he  had  an  operation.  Two  years  ago  the  patient  was  thought  to 
have  Bright's  disease  on  account  of  the  frequent  passage  of  large  quan- 
tities of  urine.  After  that  there  was  a  gradual  increase  in  the  frequency 
of  urination,  but  without  difficulty,  pain  or  dribbling.  Six  months  ago 
he  had  difficulty  in  voiding  for  the  first  time.  There  was  a  constant 
desire  with  frequent  voiding  of  small  amounts  and  almost  constant 
dribbling  of  urine.  About  the  same  time  he  began  to  have  pain  of  a 
stinging,  burning  character,  extending  from  the  neck  of  the  bladder  to 
the  meatus,  and  occasionally  severe  paroxysms  in  this  region.  The  con- 
dition gradually  grew  worse,  and  three  weeks  ago  he  began  to  use  a 
catheter  at  first  only  once  at  night,  and  since  then  more  frequently. 
Catheterization  is  difficult  and  is  generally  done  by  an  attendant.  With 
its  use  he  gets  some  comfort,  but  without  it  voids  six  or  eight  times 
during  the  night,  and  cannot  sleep  on  account  of  the  pain.  He  has  never 
had  hematuria  nor  any  pain  in  the  rectum,  thighs,  legs  or  back.  It  is 
worse  when  the  bladder  becomes  full  and  during  urination  and  is  located 
in  the  neck  of  the  bladder  and  urethra.  He  has  lost  ten  pounds  during 
the  past  few  years  and  has  become  considerably  weaker.  He  has  suffered 
considerably  from  constipation  and  a  difficult  stool  causes  pain  in  the 
bladder. 


570  Hugh  H.  Young. 

Sexual  powers. — Sexual  desire  and  erections  are  still  present.  Coitus 
satisfactory,  ejaculations  not  painful. 

Examination. — The  patient  is  a  well  nourished  man,  with  lips  of  good 
color,  but  he  seems  unusually  weak.  There  is  a  cataract  in  the  right 
eye  and  a  post  operative  coloboma  in  the  left.  The  chest  is  funnel-shaped, 
the  costal  angle  being  markedly  increased.  Expansion  is  equal,  but  ex- 
piration is  prolonged  and  the  percussion  note  hyperresonant.  The  heart 
is  not  enlarged  and  the  sounds  are  clear.  Pulse  76,  regular,  with  good 
volume,  slight  arterio-sclerosis.     The  abdomen  is  negative. 

Genitalia. — There  is  a  slight  hydrocele  on  the  left  side. 

Rectal. — The  prostrate  is  considerably  enlarged,  particularly  in  the 
transverse  diameter.  The  surface  is  irregular,  and  the  consistence  of 
an  extreme  hardness.  The  induration  extends  upward  into  the  region  of 
the  seminal  vesicles  on  both  sides,  and  there  is  also  an  intravesicular 
mass  of  induration  the  upper  end  of  which  can  be  reached  with  difficulty. 
Running  upward  and  outward  on  the  right  side  are  several  hard  cords 
which  extend  along  the  walls  of  the  pelvis  beyond  the  reach  of  the  finger, 
they  are  also  present  on  the  left  side.  No  enlarged  glands  can  be  felt. 
The  rectum  is  soft,  but  closely  adherent  to  the  prostate. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  756  cc.  residual 
urine.  The  bladder  capacity  is  large.  The  cystoscope  could  not  be  intro- 
duced owing  to  an  obstruction  about  one  inch  behind  the  external  sphincter 
apparently  at  the  median  portion  of  the  prostate.  With  the  finger  in  the 
rectum  it  is  felt  to  pass  through  the  apex  of  the  prostate  without  meeting 
obstruction,  but  it  is  impossible  to  get  it  into  the  bladder  and  considerable 
hemorrhage  was   produced. 

Urinalysis. — Cloudy,  1017,  acid,  no  sugar,  albumin  in  small  amount, 
microscopically  pus  cells. 

Remark. — The  patient's  physician  was  told  that  a  catheter  life  was  the 
safest  method  of  treatment.  He  argued  that  the  patient  would  rather 
die  than  continue  to  suffer  as  he  had,  and  that  he  would  not  be  able  to 
use  the  catheter  and  strongly  urged  a  partial  perineal  prostatectomy.  Al- 
though the  patient  was  weak  there  had  been  so  little  loss  of  weight  that 
it  was  thought  possible  to  do  a  perineal  enucleating  prostatectomy  with- 
out much  danger. 

Operation  March  20,  1906. — Ether.  Perineal  prostatectomy  by  the  tech- 
nique usually  employed  for  benign  hypertrophy.  After  incision  of  the 
membranous  urethra  very  great  difficulty  was  found  in  introducing  the 
tractor  into  the  bladder,  owing  to  a  greatly  contracted  condition  of  the 
entire  prostatic  urethra,  and  much  valuable  time  and  a  fair  amount  of 
blood  was  lost  while  attempting  to  get  various  instruments  into  the 
bladder.  Finally  the  tractor  was  introduced  and  the  operation  carried 
out  without  very  much  difficulty.  The  posterior  surface  of  the  prostate 
was  quite  adherent  to  the  rectum  and  had  to  be  freed  very  carefully. 
The  lateral  lobes  of  the  prostate  were  enucleated  with  the  aid  of  finger 
and  scissors  quite  completely.     It  was  then  thought  best  to  remove  the 


An  Operation  for  Cancer  of  Prostate.  571 

suburethral  and  median  portions  of  the  prostate,  and  in  so  doing  the 
floor  of  the  urethra  was  removed.  The  tissue  was  evidently  carcinomatous 
and  the  disease  extended  well  beyond  the  limits  of  the  prostate.  There 
was  apparently  very  little  intravesical  outgrowth.  There  was  more  hemor- 
rhage than  the  usual  prostatectomy,  but  the  patient's  pulse  did  not  rise 
above  92,  and  was  90  at  the  end  of  the  operation.  An  infusion  was  be- 
gun early  in  the  operation.  Double  tube  drainage  and  lateral  gauze  packs 
for  the  lateral  cavities  were  provided,  the  levators  were  approximated 
and  the  skin  wound  partially  closed  with  catgut  as  usual.  Continuous 
Irrigation  on  return  to  ward. 

Subsequent  course. — On  return  to  ward  the  pulse  was  80  and  regular. 
Patient  was  restless  and  complaining  of  pain.  At  6.30,  two  hours  after 
the  operation,  his  pulse  was  88.  He  was  seen  by  the  ward  physican  and 
his  condition  was  very  satisfactory.  Three  hours  later  his  pulse  was 
weak,  112,  and  his  hands  were  somewhat  cold.  The  irrigation  fluid  was 
bloody  but  not  excessively  so,  and  there  was  a  moderate  amount  of  blood 
in  the  dressings.  An  infusion  was  started  and  pressure  put  upon  the 
pads  over  the  wound.  After  that  he  slept  well,  and  his  pulse  during 
the  night  ranged  from  112  to  116.  About  6  a.  m.  he  became  much  weaker 
and  his  pulse  difficult  to  count.  When  seen  by  the  ward  physician  he 
was  in  a  stupor,  respirations  32  to  the  minute;  he  was  difficult  to  arouse 
and  the  pulse  could  not  be  counted.  There  had  been  no  hemorrhage  since 
the  evening  before  and  the  irrigating  fluid  was  running  clear.  An  infusion 
was  started,  and  at  8  a.  m.  a  transfusion  was  begun.  For  a  while  after 
this  the  patient  rallied,  and  at  10  o'clock  the  pulse  was  132  to  the  minute 
and  fairly  strong,  and  the  patient  answered  questions.  He  was  given 
frequent  hypodermics  of  brandy  and  strychnia,  also  ergotole  and  digitalin, 
and  the  pulse  remained  fairly  good  until  2.45  p.  m.  In  the  meantime  the 
respirations  had  been  becoming  gradually  shallower  and  more  rapid,  and 
the  pulse  soon  became  very  weak,  and  the  patient  died  at  4.25  p.  m.,  24 
hours  after  the  operation. 

Autopsy. — Showed  no  intravesical  hemorrhage,  no  extravasation  of  blood 
into  prevesical  or  perirectal  spaces. 

Pathological  examination. — The  specimen,  G.  U.  257,  consists  of  eight 
pieces,  the  lateral  lobes  being  much  the  larger.  The  lateral  lobes  are  hard 
in  consistency,  and  on  cutting  give  a  gritty  sensation.  The  cut  surface 
shows  no  lobulation,  but  presents  a  rather  smooth,  dense  appearance, 
with  slight  yellowish  specks  here  and  there.  Numerous  hemorrhagic 
points  are  seen  scattered  throughout  the  surface. 

Tissue  comprising  the  median  bar  and  intravesical  portion  show  no 
involvement  of  carcinoma.  Portion  of  the  left  seminal  vesicle  is  attached 
to  the  upper  end  of  the  left  lateral  and  the  carcinoma  has  apparently 
invaded  this  region.  On  gross  examination  it  would  seem  that  the 
carcinoma  has  involved  both  lateral  lobes  in  their  entire  extent,  and  then 
has  travelled  up  posteriorly  into  the  region  of  the  seminal  vesicles,  ap- 
parently sparing  the  prostatic  tissue  about  the  vesical  orifice.  This 
method  of  the  extension  of  the  disease  has  been  noted  in  other  cases. 


572  Hugh  H.  Young. 

At  autopsy  it  was  found  that  the  entire  posterior  portion  of  the  prostate 
and  prostatic  urethra  had  been  removed.  The  growth  involved  both  vesi- 
cles and  intravesicular  space  and  had  apparently  infiltrated  the  posterior 
wall  of  the  bladder  in  the  region  of  the  trigone,  but  had  not  broken 
through  into  the  bladder,  the  vesical  mucosa  being  smooth.  The  right 
seminal  vesicle  is  involved  clear  to  its  tip  and  converted  into  a  dense, 
hard  mass,  but  the  tip  of  the  left  seminal  vesicle  was  apparently  free 
from  disease.  Both  vasa  deferentia  in  their  lower  portions  were  so 
involved  in  the  carcinomatous  mass  that  it  was  impossible  to  dissect 
them  free.  The  lower  end  of  the  ureter  was  not  involved  on  either  side, 
although  the  right  seminal  vesicle  was  in  very  close  proximity  to  the  lower 
end  of  the  ureter  on  that  side.  Extensive  metastases  to  the  pelvic  glands 
are  present,  some  of  the  glands  being  several  cm.  in  diameter. 

Microscopic  examination. — Sections  from  the  lateral  lobes  show  a  car- 
cinoma in  which  numerous  small,  irregular  shaped,  mostly  elongated 
acini  are  present,  in  a  rather  abundant  stroma.  The  acini  are  lined  by 
cells,  irregular  in  size  and  staining  qualities,  and  the  same  might  be 
said  of  the  nuclei.  The  acini  often  lose  their  lumen,  and  one  sees  nothing 
but  strands  of  cancer  cells  in  between  the  stroma  bundles.  Sections 
taken  from  about  the  vesical  orifice  in  its  lower  portion  show  this  tissue 
largely  uninvaded.  The  greatest  number  of  the  sections  from  the  lateral 
lobes  show  a  carcinoma  of  a  distinct  scirrhus  type  (see  Fig.  12)  with  a 
large  amount  of  stroma,  some  tendency  to  the  formation  of  acini  being 
noted  here  and  there.  Sections  taken  from  the  region  of  the  seminal 
vesicles  show  the  walls  of  the  vesicles  invaded  by  scattered  nests  of  cancer 
cells  with  no  tendency  to  form  acini.  The  lumen  of  the  vesicle  is  appar- 
ently not  invaded.  In  a  section  from  one  of  the  metastatic  pelvic  glands, 
the  gland  tissue  is  found  entirely  replaced  by  cancer  growth  of  an  adeno- 
matous type. 

The  carcinoma  in  this  case  is  almost  entirely  of  the  scirrhus  variety 
except  in  some  few  areas  where  a  formation  of  small,  irregular  acini  is 
to  be  seen.    The  metastases  to  the  glands  are  of  the  adenocarcinoma  type. 

Case  14. — Carcinoma  of  prostate  and  seminal  vesicles;  duration  one  year, 
malignancy  not  recognized.     Partial  perineal  prostatectomy.     Improved. 

S.  No.  19,016.    J.  M.  P.,  age  60,  married,  admitted  April  11,  1906. 

Complaint. — "  Retention  of  urine." 

No  history  of  gonorrhoea. 

Present  illness. — For  about  one  year  the  patient  had  to  get  up  two  or 
three  times  at  night  to  urinate,  but  he  nas  had  no  particular  difficulty 
until  10  days  ago  when  urination  became  frequent  and  difiicult.  This 
steadily  increased  until  yesterday,  when  he  was  unable  to  void  at  all. 
His  physican  attempted  to  catheterize  him,  but  was  unable  to  introduce  a 
catheter.  The  bladder  was  then  aspirated  suprapubically,  since  then  he 
has  not  voided.  There  is  no  history  of  pain  in  back,  hips  or  thighs  and 
he  has  never  had  hematuria. 


An  Operation  for  Cancer  of  Prostate.  573 

Examination. — The  patient  is  a  well  nourished  man.  Heart,  lungs,  and 
abdomen  are  negative.  The  glands  in  the  groin  are  palpable  and  about 
the  size  of  a  small  pea. 

Rectal. — The  prostate  is  considerably  enlarged,  irregular,  somewhat 
nodular  and  indurated.  The  right  lobe  is  larger  than  the  left  and  extends 
somewhat  into  the  region  of  the  seminal  vesicles  both  of  which  are 
indurated.  Several  hard  movable  glands  the  size  of  a  pea  are  palpable. 
The  rectal  mucosa  is  soft  and  not  adherent.  The  patient  has  complete 
retention  of  urine  and  is  unable  to  void.  He  is  catheterized  with  some 
difllculty  and  a  considerable  amount  of  urine  withdrawn. 

Urinalysis. — Catheterized  specimen.  Bloody,  1015,  acid,  no  sugar,  al- 
bumin in  moderate  amount.    Microscopically  red  blood  corpuscles. 

Treatment. — The  patient  was  catheterized  for  six  days  at  regular  inter- 
vals. He  was  unable  to  void  and  suffered  considerable  pain  in  the  bladder 
and  penis.  The  urine  is  continually  bloody  and  on  this  account  the 
operator  thought  that  cystoscopy  would  be  impossible. 

April  17,  1906. — Operation.  Ether.  Perineal  prostatectomy  by  the  usual 
technique  for  benign  hypertrophy  (malignancy  not  having  been  recog- 
nized). The  rectum  was  stripped  from  the  prostate  with  more  difficulty 
than  usual  owing  to  adhesions.  The  prostate  was  not  greatly  enlarged 
and  quite  hard.  The  usual  lateral  incisions  were  made  on  each  side  of  the 
urethra  and  the  lobe  of  the  prostate  removed.  The  left  lobe  was  very 
slightly  enlarged  being  hardly  more  than  2  or  3  cm.  in  diameter,  but  the 
right  lobe  was  a  little  larger,  measuring  2x3x4  cm.  in  size. 

Considerable  difficulty  was  experienced  in  enucleating  the  lobes  owing 
to  intimate  adhesions  to  the  capsule.  (No  note  made  as  to  the  median 
portion  of  the  prostate,  but  apparently  none  was  removed.)  Frozen 
sections  were  made  at  once  by  Dr.  Geraghty  and  showed  definite  carcinoma. 
"  Radical  operation,  however,  seemed  to  present  very  little  hope  of  cure." 
The  cavities  were  packed  with  iodoform  gauze,  double  drainage  tubes 
inserted  into  the  bladder,  the  levator  muscles  drawn  together  with  catgut 
and  the  skin  wound  closed  with  interrupted  sutures  of  catgut.  The  patient 
stood  the  operation  well.  Infusion  and  continuous  irrigation  on  return 
to  the  ward. 

Convalescence. — The  patient  reacted  well.  The  temperature  rose  to  101° 
on  the  night  after  the  operation,  but  was  normal  on  the  second  day  and 
remained  so.  The  tubes  and  gauze  were  removed  24  hours  after  the 
operation.  He  was  out  of  bed  on  the  second  day  after  the  operation  and 
voided  urine  through  the  anterior  urethra  on  the  thirteenth  day.  He  was 
discharged  on  the  17th  day  in  excellent  condition,  the  perineal  wound 
completely  closed  and  voiding  urine  naturally  through  the  urethra,  with 
fairly  good  control  but  with  considerable  urgency. 

Rectal. — "  In  the  region  of  the  right  lobe  there  is  a  firm  smooth  mass 
3  or  4  cm.  in  diameter.  On  the  left  side  there  is  a  much  smaller  mass  2  cm. 
in  diameter,  the  median  portion  is  present.  The  seminal  vesicles  are 
indurated  and  there  is  no  induration  of  the  base  of  the  bladder.  Glands 
are  present  in  the  groin,  about  1  or  2  cm.  in  diameter  but  are  soft." 


574  Hugh  H.  Young. 

Pathological  examination. — The  specimen,  G.  U.  279,  consists  of  two 
pieces,  the  left  and  right  lateral  lobe.  The  right  lateral  lobe  is  a  mass 
weighing  about  4  gm.,  its  consistency  is  firm  and  cuts  as  though  ex- 
tremely dense.  The  cut  surface  of  the  mass  has  a  yellowish  granular 
appearance  with  numerous  small  seed  calculi  scattered  throughout,  and 
the  tissue  presents  none  of  the  typical  picture  of  prostatic  hypertrophy. 

A  frozen  section  was  made  from  the  tissue,  and  showed  it  to  be  an 
adenocarcinoma.  The  left  lobe  is  a  mass  weighing  about  1  gm.,  and  has 
the  same  character  as  the  right  lateral. 

Microscopic  examination. — A  section  from  the  right  lateral  lobe  shows 
an  adenocarcinoma  with  a  moderate  amount  of  stroma.  At  times  one 
sees  areas  where  acini  seem  fairly  normal  and  are  lined  by  a  normal 
looking  epithelium,  but  in  other  areas  the  acini  are  atypical  and  lined 
by  epithelium  showing  involution.     (See  Fig.  17.) 

Occasionally  one  sees  an  acinous  where  the  epithelium  in  breaking 
through  and  infiltrating  the  immediate  stroma.  At  times  the  acini  are 
filled  with  cancer  cells.  In  the  section  from  the  periphery  of  the  right 
lobe  and  including  some  periprostatic  tissue  one  finds  carcinoma,  simplex 
type.  Solid  alveoli  of  cells  are  present  in  the  areolar  tissue.  Masses  of 
cancer  are  present  in  the  lymphatic  spaces  about  the  larger  blood-vessels, 
and  in  several  places  have  invaded  the  small  nerve  bundles.  The  type  of 
cells  which  one  sees  in  this  extraprostatic  extension  of  the  disease  is  rather 
peculiar,  the  cells  are  rather  polygonal,  clear  and  with  a  round  small 
nucleus,  but  the  nuclei  may  vary  in  size  a  great  deal.  They  suggest 
cells  of  endothelial  origin. 

C.     SuPEAPUBic  Peostatectomy,  Two  Cases. 

The  prostate  has  been  enucleated  suprapubically  in  two  cases,  in 
both  of  which  the  malignant  nature  of  the  disease  was  not  recognized. 
One  of  these  was  operated  in  1898  by  another  surgeon  and  resulted  in 
death  30  hours  after  the  operation.  Autopsy  showed  numerous  pelvic 
metastases.  •  In  the  second  case  which  is  given  in  full  in  the  previous 
paper  I  failed  to  recognize  the  malignant  nature  of  the  disease  and 
performed  suprapubic  prostatectomy  after  removing  a  very  large 
vesical  calculus.  It  was  impossible  to  separate  the  prostatic  lobes 
from  the  urethra,  and  the  entire  prostate  was  shelled  out  in  one  mass 
along  with  its  urethra.  The  malignant  nature  of  the  disease  was  not 
discovered  until  several  years  later,  when  the  patient  returned  com- 
plaining of  a  tumor  of  the  kidney.  He  reported  that  there  was  no 
difficulty  or  frequency  of  urination  and  that  the  operation  had  cured 
him  completely.  Eectal  examination,  however,  showed  an  indurated 
mass  in  the  region  of  the  prostate  and  study  of  the  microscopic  sec- 
tions of  the  prostate  removed  at  operation  showed  carcinoma,  thus 


An  Operation  for  Cancer  of  Prostate.  575 

explaining  the  nature  of  the  supposed  kidney  tumor.  The  patient 
died  four  years  after  the  operation,  having  been  entirely  free  from 
urinary  disturbance. 

Case  15. — Carcinoma  of  prostate  and  seminal  vesicles.  Metastases  of 
numerous  glands.  Duration  two  years.  Complete  retention  of  urine. 
Suprapubic  prostatectomy.    Death. 

S.  No.  7455.    C.  B.,  age  67,  married,  admitted  February  23,  1898. 

Complaint. — "  Dribbling  of  urine  and  bleeding  from  urethra." 

The  patient  is  in  a  very  weak  condition  and  it  is  impossible  to  get  a 
very  accurate  history.  The  present  illness  apparently  began  two  years 
ago  with  frequency  of  urination.  Since  then  there  has  been  a  gradual 
increase  in  difficulty  and  frequency  of  urination,  and  of  late  he  has  had 
considerable  pain.  Complete  retention  of  urine  came  on  12  days  ago,  and 
he  was  catheterized  twice.  Since  then  he  has  been  able  to  pass  urine  in 
small  amounts  and  has  had  considerable  hemorrhage. 

Status  prcesens. — Continuous  dribbling  of  urine,  occasional  hemorrhage, 
much  exhaustion,  great  deal  of  pain  (location  not  noted). 

Examination. — The  patient  is  a  sparely  nourished  old  man,  with  very 
pale  mucous  membranes.  Lungs  negative.  Heart:  A  soft  systolic  murmur 
at  apex. 

Abdomen. — The  abdomen  is  distended  and  palpation  and  percussion 
reveal  a  bladder  which  extends  above  the  umbilicus.  The  abdominal 
muscles  are  tense  and  examination  is  painful. 

Rectal. — The  prostate  is  pushed  towards  the  anus  by  an  over-distended 
bladder.  It  is  considerably  enlarged,  irregular  and  nodular,  but  the  surface 
is  smooth  rather  than  rough,  and  the  consistence  very  hard.  (No  note 
made  as  to  the  seminal  vesicles  and  regions  above.) 

Operation. — Owing  to  the  traumatism  that  had  been  produced  by  previous 
attempts  at  catheterization  the  bladder  was  aspirated  through  the  supra- 
pubic region,  and  1300  cc.  urine  removed. 

Urinalysis. — Urine  very  dark,  bloody.  Microscopically  red  blood  cor- 
puscles, no  bacteria. 

Treatment. — During  the  next  six  days  a  catheter  was  passed  once  and 
1400  cc.  bloody  urine  withdrawn.  Numerous  other  attempts  at  catheter- 
ization were  unsuccessful,  and  the  patient  was  aspirated  seven  times. 
The  condition  of  the  patient  improved,  though  he  was  still  quite  weak,  and 
the  urine  became  clear.  As  catheterization  was  still  impossible,  operation 
for  drainage  became  necessary. 

Operation,  March  1,  1898. — Dr.  Gushing.  Suprapubic  cystostomy  for 
drainage.  Partial  prostatectomy.  The  prostatic  orifice  was  small  and  sur- 
rounded by  a  mass  of  prostatic  enlargement  which  had  the  appearance  of 
a  huge  cervix  uteri.  There  were  no  clefts  and  no  middle  lobe  present.  On 
the  surface  of  the  prostatic  mass  were  several  small  pedunculated  bodies 
whitish  in  color,  and  one  papillomatous  tumor  the  size  of  a  cherry.  The 
bladder  was  thickened  and  trabeculated,  but  there  was  no  vesical  tumor  or 


576  EugJi  E.  Young. 

ulcer  present.  A  V-shaped  incision  was  made  in  the  median  portion  of 
the  prostate,  and  several  fairly  large  lobules  of  prostatic  tissue  removed 
by  enucleation.  An  attempt  was  made  to  remove  the  lateral  lobes  of  the 
prostate,  but  it  was  found  impossible  to  enucleate  them.  The  bladder 
was  closed  around  a  drainage  tube  and  the  muscles  drawn  together  with 
sutures. 

Sulisequent  notes. — The  patient  recovered  from  the  operation  well,  and 
had  a  comfortable  night.  On  the  following  afternoon  his  pulse  became 
very  small,  there  was  very  little  urine  excreted.  His  condition  grew 
gradually  weaker  and  he  died  about  30  hours  after  the  operation. 

Autopsy. — Carcinoma  of  the  prostate,  metastases  to  pelvis,  abdominal 
and  retroperitoneal  lymph  glands,  to  seminal  vesicles  and  to  the  right 
kidney.  Acute  pyelitis,  pyelonephritis.  Tuberculosis  of  lungs.  Beginning 
broncho-pneumonia.  There  was  a  large  glandular  mass  at  the  bifurcation 
of  the  aorta,  and  at  the  bifurcation  of  the  iliacs  on  both  sides.  Metastatic 
gland  at  the  neck  of  the  gall  bladder.  Metastatic  processes  could  be 
followed  up  along  the  lymph  glands  as  far  as  the  pancreas.  There  were 
numerous  enlarged  glands  in  the  pelvis.  The  prostate  had  grown  largely 
toward  the  bladder.  An  irregular  cavity  was  present  in  the  median  portion 
from  which  the  operator  had  removed  a  small  part  of  the  enlargement. 
The  bladder  itself  was  free  from  disease.  Examination  of  the  posterior 
surface  of  the  prostate  showed  a  large  rounded  surface,  somewhat  irregular 
in  contour.  The  seminal  vesicles  were  contracted,  much  smaller  than 
normal,  and  situated  upon  the  posterior  surface  of  the  prostatic  mass, 
and  apparently  not  involved.  The  ureters  appeared  normal,  and  there  was 
no  carcinoma  adjacent  to  them. 

Microscopic  sections  showed  carcinoma  of  the  median  portion  of  the 
prostate  removed  at  operation;  of  the  portion  of  right  lobe  of  prostate  and 
of  the  papilloma  excised  from  left  lobe  of  prostate  at  operation;  of  the 
seminal  vesicles  (which  were  entirely  replaced  by  carcinoma),  and  of 
glands  from  the  bifurcation  of  iliac  vessels  and  near  the  rectum.  The 
trigone  was  not  involved  by  the  carcinoma. 

The  carcinoma  presents  varying  pictures.  In  quite  extensive  areas  one 
finds  a  typical  carcinoma  simplex,  large  alveoli  filled  with  epithelium,  and 
surrounded  by  firm  bands  of  fibrous  tissue.  At  times  these  alveoli  are 
numerous  and  lie  close  together  with  slender  bands  of  stroma  interlacing 
between  the  alveoli,  and  at  times  insinuating  their  way  in  the  alveoli 
and  partially  subdividing  them.  In  other  areas  the  carcinoma  assumes 
adenoma  type  often  grouped  in  areas  where  they  are  much  in  excess  of 
the  stroma.  Here  and  there  one  finds  both  in  the  adenomatous  and  the 
alveolar  portions  a  marked  tendency  to  infiltrate  the  stroma. 

A  section  from  a  metastatic  gland  shows  a  diffuse  carcinomatous  in- 
volvement without  any  tendency  to  formation  of  acini. 

Case  16. — Carcinoma  of  the  prostate.  Suprapubic  prostatectomy  in- 
cluding the  urethra.  Excellent  result,  no  further  urinary  disturbances. 
Death  from  retroperitoneal  metastases  four  years  later.  (See  Case  II.  in 
previous  paper.) 


An  Operation  for  Cancer  of  Prostate.  577 

D.     BoTTiNi  Operation,  Seven  Cases. 

The  Bottini  operation  was  employed  to  relieve  prostatic  obstruction 
in  seven  cases.  In  four  of  these  cases  the  diagnosis  of  carcinoma  was 
made,  and  the  operation  employed  simply  as  a  palliative  procedure 
with  distinct  improvement  in  all  four  cases.     (Cases  17,  19,  32,  and  8). 

In  three  cases  (Cases  18,  20  and  21),  the  malignant  nature  of  the 
enlargement  was  not  recognized,  and  the  Bottini  operation  was  em- 
ployed, as  I  was  using  it  to  the  exclusion  of  other  methods  at  that 
time.  The  results  obtained  were  very  good  in  all  three  cases.  In 
one  case  the  obstruction  recurred  and  the  patient  died  within  a  year 
(Case  18).  In  the  second  case  (Case  21;)  the  result  was  excellent  for 
16  months  when  symptoms  of  obstruction  again  appeared,  and  supra- 
pubic cystotomy  for  drainage  had  to  be  employed  three  years  after 
the  Bottini  operation.  The  last  case  (Case  20)  has  been  remarkable 
for  the  immense  benefit  conferred  by  the  Bottini  operation.  He  is 
now  almost  four  years  after  the  Botti  operation  free  from  pain  and 
discomfort,  although  the  prostate  and  seminal  vesicles  are  markedly 
involved  and  general  glandular  metastases  are  present. 

A  review  of  these  seven  cases  shows  several  remarkable  results  with 
the  Bottini  operation,  and  it  is  a  question  yet  to  be  decided  as  to 
whether  it  or  perineal  prostatectomy  is  the  preferable  operation  where 
it  is  desired  to  relieve  the  patient  from  the  necessity  of  painful  and 
difficult  catheterization,  and  the  discomforts  of  life  with  a  suprapubic 
drainage  apparatus. 

These  cases  were  all  operated  upon  by  the  writer  and  are  as  fol- 
lows: 

Case  17. — Carcinoma  of  prostate  and  se'rninal  vesicles.  Duration  four 
months.  Great  frequency  and  large  residual.  Bottini  operation.  Im- 
provement.    Death  within  a  year. 

No.  161.     J.  T.  T.,  age  53  years,  widowed,  admitted  October  2,  1899. 

Complaint. — "  Bladder  trouble." 

No  previous  history  of  gonorrhoea. 

About  12  years  ago  the  patient  began  to  have  frequency  of  urination 
and  pain  in  the  bladder  and  urethra.  This,  however,  passed  off  soon  and 
he  had  no  further  trouble  until  eight  years  ago,  when  frequency  of 
urination  and  hematuria  recurred.  After  that  there  was  very  little  trou- 
ble until  four  months  ago,  since  which  time  he  has  had  great  frequency 
and  difficulty  of  urination,  but  there  has  been  no  hematuria  and  no  note 
was  made  of  pain. 

8.  P. — Micturition  at  very  frequent  intervals  and  with  considerable 
difficulty;   no  hematuria,  no  pain  complained  of. 


578  Eugli  H.  Young. 

Examination. — A  fairly  well  nourished  man.  Arteries  slightly  thickened, 
lungs  moderately  emphysematous.     Heart  sounds  normal. 

Abdomen. — The  bladder  is  considerable  dilated,  palpable  several  inches 
above  the  pubes. 

Rectal. — The  prostate  is  greatly  enlarged,  being  about  the  size  of  an 
orange.  The  surface  is  very  hard,  and  irregular,  with  small  nodules. 
In  the  region  of  the  left  seminal  vesicle  is  a  very  large,  hard  mass,  which 
extends  upward  and  outward  along  the  pelvic  wall,  and  above  it  several 
indurated  lymphatics  can  be  felt.  No  note  made  as  to  the  condition  of 
the  right  seminal  vesicle  nor  as  to  enlarged  glands. 

Instrumental. — A  silver  catheter  passes  with  ease  and  finds  850  cc. 
residual  urine.  The  bladder  tonicity  is  good.  Total  urethral  length  is 
9%  inches.  With  finger  in  rectum  and  catheter  in  urethra  it  is  impos- 
sible to  feel  the  beak  when  turned  downward,  owing  to  great  increase 
in  thickness  in  the  subtrigonal  and  median  prostatic  tissues. 

Diagnosis  of  carcinoma  was  made,  but  owing  to  distress  of  the  patient 
aBottini  operation  was  suggested  as  a  means  of  relief. 

Operation,  Xovemher  21,  1899. — Bottini  operation.  Four  per  cent  eucaine 
was  injected  into  the  urethra.  Three  cuts  were  made,  each  about  3  cm. 
in  length,  with  current  at  white  heat.  There  was  very  little  hemorrhage. 
The  patient  stood  the  operation  well,  and  voided  urine  more  easily  after- 
wards. 

Convalescence. — The  patient  had  no  chill  and  passed  a  fairly  comfort- 
able night  after  the  operation.  He  voided  urine  quite  freely  and  had  very 
little  hemorrhage.  On  the  third  day  after  the  operation  he  returned  for 
examination;  the  urine  was  clear,  he  was  voiding  quite  easily  and  felt 
greatly  improved.  He  was  seen  about  four  months  after  the  operation; 
his  condition  was  very  greatly  improved,  and  he  was  at  work.  The  inter- 
val between  urination  was  as  long  as  three  hours  during  the  day  and 
only  four  times  at  night.  There  was  still  some  straining  during  micturi- 
tion. Examination  of  the  prostate  showed  about  the  same  condition  as 
before  operation. 

November,  1901. — The  patient  cannot  be  found,  and  it  is  reported  that 
he  is  dead. 

Case  18. — Reported  in  full  in  previous  paper,  Case  III.  Carcinoma  of 
prostate  and  seminal  vesicles,  frequent  and  difficult  urination,  completely 
relieved  by  Bottini  operation.    Death  one  year  later. 

Case  19. — Carcinoma  of  prostate  and  vesicles.  Duration  eight  months. 
Complete  retention  of  urine,  catheter  life. — Bottini  operation. 

No.  291.     S.  D.  D.,  age  62,  married,  admitted  May  28,  1902. 

Complaint. — "  Enlarged  prostate." 

Denies  gonorrhoea. 

Present  illness  began  eight  months  ago  with  difliculty  in  urination.  This 
gradually  increased  until  finally  complete  retention  of  urine  came  on 
and  since  then  he  has  led  a  catheter  life.     He  is  now  unable  to  void  urine. 


An  Operation  for  Cancer  of  Prostate.  579 

and  has  lost  considerably  in  weight  and  strength.  No  note  as  to  pain 
or  hematuria. 

Examination. — The  patient  is  thin  and  weak.  His  lips  are  of  fair  color, 
heart,  lungs  and  abdomen  negative. 

Rectal. — The  prostate  is  moderately  enlarged,  very  irregular,  nodular 
and  hard.     (Notes  in  regard  to  the  seminal  vesicles  lost.) 

Cystoscopic. — A  catheter  passes  with  ease,  the  bladder  is  contracted  and 
is  very  irritable.  Cystoscopic  examination  showed  an  intravesical  en- 
largement of  the  prostate,  very  irregular  in  character,  certainly  malignant. 
Examination  unsatisfactory  on  account  of  hemorrhage. 

Operation  May  30,  1902. — Local  cocaine  anesthesia.  Bottini  operation. 
One  median  and  two  lateral  cuts,  each  about  3  cm.  in  length.  During 
the  operation  the  finger  was  kept  in  the  rectum.  Patient  stood  the 
operation  well.    There  was  very  little  hemorrhage  and  no  pain. 

Convalescence. — The  patient  had  a  slight  chill,  but  was  in  good  con- 
dition the  next  day.  On  the  day  after  the  operation  he  voided  1075  cc. 
in  14  urinations,  the  amounts  varying  from  55  to  100  cc.  He  did  not 
require  catheterization  after  operation,  and  left  the  hospital  on  the 
seventh  day,  voiding  urine  in  a  fairly  good  stream  without  pain  or  diffi- 
culty, and  feeling  well. 

April  10,  1906. — Letter  from  physician.  After  returning  home  the 
patient  had  pain  in  the  region  of  the  prostate,  hematuria,  and  continued 
loss  of  flesh.  Urination  did  not  become  more  difficult  and  catheterization 
was  not  necessary.  He  was  not  troubled  with  constipation  or  any  rectal 
trouble,  and  no  further  operation  was  necessary.  The  patient  died  August 
24,  1902. 

Case  20. — Reported  in  full  in  previous  paper,  Case  IV.  Carcinoma  of 
prostate,  malignancy  not  suspected.  Excellent  result.  Entirely  comfort- 
able now  four  years  after  Bottini  operation. 

Case  21. — Reported  in  full  in  previous  paper,  Case  V.  Carcinoma  of 
prostate  and  seminal  vesicles.  Excellent  result  after  Bottini  operation 
maintained  16  months.  Suprapubic  drainage.  Death  several  weeks  later, 
two  years  after  Bottini  operation. 

Case  22. — Carcinoma  of  prostate  with  Idrge  intravesical  lobes  and  in- 
volvement of  vesicles.     Bottini  operation.     Death.     Autopsy. 

No.   623.     G.   S.,  age  72,  married,   admitted  January  20,  1904. 

Onset  one  year  ago  with  difficulty  and  frequency  of  urination.  This 
increased  rapidly  and  six  months  later  patient  had  complete  retention  of 
urine.  Since  then  he  has  been  unable  to  void  voluntarily.  No  history 
of  hematuria.  Of  late  he  has  suffered  severely  of  pain  in  the  course  of 
the  sciatic  nerve  and  right  leg  is  swollen.     Has  lost  weight  and  strength. 

General  examination. — Anemic,  weak  looking  man.  The  right  foot,  leg 
and  thigh  are  swollen  and  cedematous.  Examination  of  the  right  groin 
shows  an  irregular  induration  in  the  region  of  the  vessel  just  beneath 
Poupart's  ligament,  it  is  not  definite  that  this  consists  of  enlarged  glands. 


580  EugJi  H.  Young. 

Rectal. — Prostate  very  much  enlarged,  hard  and  irregular.  Large  no- 
dules forming  the  posterior  surface.  It  is  apparently  closely  adherent 
to  rectum  and  the  induration  extends  upwards  into  the  region  of  both 
seminal  vesicles.  The  prostate  extends  far  to  the  right  and  is  closely 
adherent  to  the  pelvic  wall.  Cystoscopic  examination  shows  a  large  col- 
lar-like intravesical  prostatic  outgrowth  with  many  large,  irregular  lobu- 
lations. No  definite  deep  sulci  as  in  simple  hypertrophy  cases,  no  ulcera- 
tion. The  diagnosis  of  carcinoma  was  made,  and  it  was  thought  best  to 
continue  to  use  the  catheter.  The  patient  suffered  so  much  pain  from 
the  use  of  a  catheter  that  he  begged  for  an  operation — a  Bottini  was  ac- 
cordingly performed.  Following  this  the  patient  was  able  to  void  urine 
without  a  catheter,  although  at  very  frequent  intervals.  He  still  had 
considerable  pain  in  the  rectum  and  down  the  posterior  surface  of  the 
right  thigh,  although  this  was  somewhat  less  severe  than  before  operation, 
but  he  continued  to  grow  weaker,  and  was  discharged  in  April,  1904. 

Autopsy. — There  is  a  hydronephrosis  of  the  right  kidnej^ — the  pelvis 
and  ureter  being  very  markedly  distended.  The  lower  end  of  the  right 
ureter  is  surrounded  by  carcinomatous  tissue  which  compresses  it.  The 
prostate  gland  is  about  the  size  of  a  duck's  egg,  and  the  interior  is  ulcer- 
ated, leaving  a  cavity  as  large  as  a  walnut  communicating  above  with  the 
bladder  and  below  with  the  urethra.  Carcinoma  has  invaded  the  wall 
of  the  bladder  until  the  walls  are  some  places  nearly  an  inch  in  thickness 
and  the  mucous  membrane  is  in  many  places  ulcerated.  The  pelvic  and 
lumbar  glands  are  slightly  enlarged,  but  a  gland  taken  from  the  lumbar 
region  shows  microscopically  no  metastases.  A  lymph  gland  from  the 
pelvis  shows  microscopically  carcinoma.  Sections  from  the  spleen  and 
liver  are  negative.  With  the  exception  of  the  carcinoma  in  the  prostate, 
bladder  and  pelvic  lymph  glands,  no  other  mention  is  made  of  carcino- 
matous involvement. 

Case  8,  in  which  a  perineal  prostatectomy  was  first  employed,  and  later 
Bottini  operation  to  relieve  recurrence  of  obstruction,  and  reported  in 
full  in  previous  paper.  Case  TI.  Slight  improvement,  death  a  few  weeks 
later. 

E.     Castration,  Ttvo  Cases, 

Castration  was  performed  for  the  relief  of  prostatic  obstruction  in 
two  cases.  In  one  case  the  operator  did  not  recognize  that  the  disease 
was  carcinomatous,  and  performed  castration,  which  was  then  in 
vogue,  in  order  to  produce  an  atroph}-  of  the  enlarged  prostate.  Supra- 
pubic cystostomy  for  drainage  was  provided  at  the  same  time.  The 
result  was  negative  and  the  patient  wore  a  suprapubic  drainage  appa- 
ratus until  the  date  of  his  death  a  3^ear  or  so  later. 

In  the  second  case  which  was  operated  on  by  the  wTiter,  the  diag- 
nosis of  carcinoma  was  evident.    There  "O'as  no  frequency  or  diiSculty 


An  Operation  for  Cancer  of  Prostate.  581 

of  urination,  bnt  the  patient  complained  of  severe  pain  in  tlie  rectum, 
buttocks  and  limbs.  No  operation  to  relieve  obstruction  was  indi- 
cated, and  castration  was  performed  with  the  hope  that  some  change 
in  the  prostate  which  might  bring  about  relief  of  the  rectal  pain,  might 
follow.  The  result,  however,  was  negative.  These  cases  are  as  fol- 
lows: 

Case  23. — Carcinoma  of  prostate  and  vesicles.  Duration  six  weeks. 
Symptoms :  Frequency  of  urination,  obstruction,  straining,  loss  of  weight. 
Suprapubic  cystostomy. 

Surgical  No.  6478.     R.  J.  C,  age  64,  married,  admitted  April  25,  1897. 

Complain. — "  Frequent  urination." 

Gonorrhoea  at  the  age  of  34,  no  gleet  or  stricture  following. 

Onset  six  weeks  ago  with  difl&culty  and  straining  at  urination,  which 
has  continued  up  to  the  present  time,  urination  being  very  frequent.  Two 
weeks  ago  he  consulted  a  physician  who,  after  rectal  examination,  told 
him  he  had  a  tumor  along  the  rectum.  He  has  not  had  complete  reten- 
tion of  urine  but  has  been  instrumented  once. 

S.  P. — Micturition  every  15  or  20  minutes,  with  great  difhculty  and 
straining.     Has  lost  ten  pounds.    Health  excellent. 

Examination. — The  patient  is  healthy  in  appearance. 

Rectal. — The  prostate  is  moderately  enlarged.  No  note  as  to  consist- 
ence. In  the  region  of  the  right  seminal  vesicle  is  an  oblong  nodular 
mass  which  is  very  hard  but  not  tender.  In  the  region  of  the  left  seminal 
vesicle  there  is  a  similar  but  smaller  and  less  nodular  mass.  A  large 
distended  bladder  can  be  felt.  On  abdominal  examination  it  is  found 
to  reach  the  umbilicus. 

Instrumental. — A  stone  searcher  is  passed  with  some  difficulty  into 
the  bladder,  owing  to  constriction  of  the  prostatic  urethra.  With  finger 
in  rectum  and  searcher  in  urethra  a  very  great  increase  in  the  suburethral 
portion  of  the  prostate  was  made  out,  and  it  is  markedly  indurated,  almost 
cartilaginous. 

The  amount  of  residual  urine  was  not  determined,  the  bladder  having 
been  aspirated  a  few  hours  before,  1000  cc.  urine  withdrawn. 

Urinalysis. — Pale,  1004,  no  albumin,  no  sugar,  microscopically  a  few 
pus  cells. 

Operation  May  3,  1897. — Double  castration.  Suprapubic  cystostomy  for 
permanent  drainage  of  bladder.  Suture  of  tube  to  bladder  wall.  Exami- 
nation with  the  finger  showed  no  enlargement  of  the  median  portion  of 
the  prostate.  The  urethral  orifice  was  small  and  admitted  the  tip  of  the 
little  finger  with  difficulty.  The  mucous  membrane  of  the  bladder  was 
smooth. 

Convalescence. — The  patient  reacted  well.  There  was  considerable  leak- 
age around  the  tube,  but  the  castration  wounds  were  protected  by  collodion. 
A  good  sinus  formed  and  a  Bloodgood  bag  was  provided.     The   patient 


582  Hugh  H.  Young. 

left  the  hospital  on  May  31,  in  excellent  condition,  the  urine  draining 
freely  into  the  bag. 

August  27,  1S97. — The  patient  is  still  wearing  the  Bloodgood  drainage 
apparatus.  He  has  lost  23  pounds  in  weight,  but  suffers  no  pain.  The 
prostate  is  still  very  firm,  but  seems  to  be  smaller  than  before  operation. 
His  sexual  power  is  preserved. 

March,  1S9S. — The  patient  complains  of  great  pain  in  the  rectum  and 
a  constant  desire  to  go  to  stool.  He  also  suffers  with  pain  in  the  lumbar 
region. 

Unfortunately  no  note  was  made  except  to  say  that  the  diagnosis  of 
the  prostate  was  made.  This  should  have  been  evident,  however,  at  the 
first  examination. 

Case  24. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  eight 
months.    Pain  a  prominent  symptom.     Operation:   Castration,  no  relief. 

No.  457.     J.  C,  age  62,  married,  admitted  August  31,  1903. 

Present  illness  began  eight  months  ago  with  pain  in  the  right  hip. 
Since  then  attacks  of  pain  have  recurred  at  frequent  intervals.  The  pain 
extends  from  the  groin  through  to  the  buttocks,  and  at  times  down  side 
and  back  of  leg  to  toes.  There  is  a  continuous  pain  in  the  rectum,  but 
worse  at  times  than  at  others.  A  very  severe  attack  of  pain  comes  on 
about  once  in  24  hours.  These  start  gradually  in  rectum  and  from  there 
spread  to  the  right  buttock,  and  down  to  the  back  of  the  right  thigh  and 
leg  to  the  sole  of  the  foot.  These  pains  have  been  so  severe  that  the 
patient  has  required  morphia.  He  has  had  very  little  trouble  with 
urination;  only  some  slight  hesitation  at  the  start.  Appetite  and  digestion 
good.    Sexual  intercourse  causes  pain. 

Examination. — The  patient  is  a  fairly  well  nourished  man,  with  lips  of 
fair  color.  General  examination  is  practically  negative  except  for  some 
tenderness  along  the  course  of  the  sciatic  nerve. 

Rectal. — The  prostate  is  very  greatly  enlarged,  projecting  far  into  the 
rectum.  In  the  center  is  a  nodule  and  the  remainder  of  the  surface  is 
slightly  nodular  or  lobulated.  The  median  furrow  is  obliterated.  The 
enlargement  is  greater  on  the  right  side  extending  up  into  the  region 
of  the  seminal  vesicle.  The  vesicles  cannot  be  made  out.  The  consistence 
is  hard  towards  the  apex,  but  at  places  further  back  it  is  elastic  and  soft. 

Cystoscopic. — The  cystoscope  shows  very  little  intravesical  hypertrophy. 
There  is  a  slight  median  bar  and  no  sulcus  present.  On  account  of  the 
slight  urinary  obstruction  and  the  fact  that  the  bowel  wall  seems  to  be 
involved  by  the  growth,  castration  (rather  than  perineal  prostatectomy), 
was  performed  for  the  relief  of  pain.  Following  the  operation  the  patient 
had  definite  mental  disturbances.  The  pain  was  not  relieved,  and  at 
times  he  stated  that  it  was  terrific. 

The  urine  was  acid,  slightly  cloudy,  Sp.  Gr.  1018,  trace  of  albumin, 
hyaline,  and  granular  casts,  some  pus  cells. 

Several  months  after  patient's  return  home  doctor  reported  that  "  he 
has  more  or  less  pain  all  the  time  in  the  rectum,  hips,  back,  and  penis." 


An  Operation  for  Cancer  of  Prostate.  583 

The  prostate  has  not  diminislied  any  in  size  and  patient  has  to  have 
opiates  constantly  to  relieve  his  pain.  The  patient  died  about  one  year 
after  onset  of  symptoms. 

April  10,  1906. — Letter.  The  patient  returned  from  the  hospital  on  the 
23d  of  September  and  grew  worse  until  the  21st  of  January  when  he  died. 

P,     Suprapubic  Cystotomy  for  Drainage,  Five  Cases. 

Suprapubic  drainage  was  provided  in  five  cases.  In  all  of  these 
cases  urination  was  frequent  and  difficult  and  catheterization  either 
very  painful  or  hard  to  accomplish.  In  case  27,  the  patient  was  in 
desperate  shape  and  suprapubic  drainage  was  supplied  as  an 
emergency  operation.  In  the  last  case  (Case  28),  the  patient  was  sub- 
ject to  severe  chills,  fever  and  sweats,  the  result  of  absorption  from 
suppurative  processes  in  the  prostatic  urethra  and  prostate  which  was 
kept  irritated  by  the  passage  of  a  catheter.  The  operation  has  had  the 
result  of  completely  doing  away  with  these  conditions  and  the  patient 
is  very  much  more  comfortable,  although  he  finds  the  suprapubic 
tube  a  great  nuisance. 

Our  cases  in  which  suprapubic  drainage  has  been  supplied  are  too 
few  to  draw  conclusions  from,  but  this  operation  undoubtedly  has  a 
valuable  place  when  catheterization  has  become  very  difficult  or  pain- 
ful and  severe  suppurative  processes  are  present.  In  some  cases,  how- 
ever, the  use  of  conservative  perineal  prostatectomy  or  the  Bottini  op- 
eration may  furnish  much  greater  comfort  for  a  certain  period  of 
time.  There  can  be  no  hard  and  fast  lines  drawn  as  to  the  preference 
among  these  methods.  Cases  of  carcinoma  of  the  prostate  are  so  varied 
that  no  one  operation  can  be  advised  for  all  cases. 

These  five  cases  are  as  follows : 

Case  23. — Carcinoma  of  the  prostate  and  seminal  vesicles.  Simultan- 
eous suprapubic  cystostomy  and  castration.  Improved.  (See  full  report 
under  cases  treated  by  castration.) 

Case  25. — Carcinoma  of  prostate,  seminal  vesicles  and  trigone.  Duration 
10  months..  Sypmtoms:  Pain,  frequency  of  urination.  Operation:  Supra- 
puhic  cystostomy. 

S.  N.  8756.     P.  D.,  age  58,  admitted  March  17,  1899. 

Onset  with  pain  in  penis  during  and  after  micturition  and  intermittent 
urination.  After  about  four  months  the  frequency  of  urination  became 
very  marked  and  he  had  complete  retention.  Has  had  retention  of  urine 
every  two  to  three  weeks  ever  since.  Pain  has  been  constant  and  increas- 
ing. 

Vol.  XIV.— 40. 


584  Hugh  H.  Young. 

S.  P. — Pain  in  penis;  frequency  of  urination  every  10  to  15  minutes  at 
night.     Constipated.     Catheterized  once  a  day. 

Examination. — Fairly  well  nourished.  Mucous  membrane  of  good  color. 
Chest  negative.  Abdomen:  Bladder  palpable  above  symphysis.  Posterior 
cervical  and  inguinal  glands  are  palpable. 

Rectal  Examination. — The  prostate  is  large,  very  hard  and  extremely 
irregular,  larger  on  the  right  than  on  the  left.  The  finger  can  reach  above 
the  main  mass  and  far  above  on  the  left  is  felt  a  firm  irregular  round 
nodule  entirely  separated  from  the  lower  mass  and  situated  much  more 
posteriorly.  Between  this  and  the  main  mass  a  very  small  nodule  can  be 
felt.  This  upper  nodule  is  freely  movable,  and  can  be  rolled  about  and 
is  evidently  an  enlarged  gland.  On  entering  hospital  the  patient  com- 
plained of  pain  in  suprapubic  and  epigastrium  regions  and  in  the  right 
flank.  There  was  intermittent  involuntary  passage  of  urine  accompanied 
by  much  pain.  A  catheter  was  introduced  with  some  difficulty,  1300  cc. 
of  bloody  urine  being  drawn  off. 

A  suprapubic  cystostomy  was  performed  as  the  patient  was  unable  to 
void  voluntarily.  At  operation  it  was  found  that  the  prostate  did  not 
project  into  the  bladder,  but  the  trigone  was  nodular,  very  hard  and 
irregular,  but  the  mucous  membrane  was  intact.  Following  operation 
the  patient  was  fairly  comfortable  for  about  four  weeks  when  he  began 
to  complain  of  considerable  pain  in  the  rectum  and  down  the  left  leg 
and  required  morphia.  No  evidence  of  disturbed  sensation  over  the  left 
leg  was  discovered.  A  note  May  8,  says,  "  there  is  no  palpable  enlarge- 
ment of  iliac  glands,  no  enlargement  of  inguinal  glands.  Liver  palpable 
two  finger  breadths  below  costal  margin,  surface  does  not  seem  smooth. 
There  is  no  jaundice."  Patient  was  discharged  May  30,  1899.  Condition 
weak  but  fairly  comfortable.  Using  Bloodgood  bag.  Urine  Sp.  gr.  1010. 
Alkaline.    No  sugar,  slight  trace  of  albumin.    Considerable  pus. 

Case  26. — Carcinoma  of  prostate  and  bladder,  large  intravesical  tumor. 
Duration  three  years.  Hematuria,  frequency  of  urination,  pain.  Oper- 
ation: Suprapubic  cystostomy. 

S.  No.  10,843.    H.  H.  G.,  age  59,  married,  admitted  August  28,  1900. 

Complaint. — "  Pain  in  penis  and  testicles,  occasional  passage  of  blood." 

Gonorrhoea  in  youth,  no  sequelae.  Slight  burning  on  urination  during 
past  10  years. 

Present  illness  began  three  years  ago  with  pain  in  the  penis  followed  by 
the  passage  of  a  small  blood  clot.  After  that  he  passed  blood  continuously 
for  a  few  days,  and  at  intervals  ever  since,  hematuria  has  been  present. 
Micturition  has  been  painful,  difficult,  and  frequent,  and  has  gotten  grad- 
ually worse.  He  has  lost  considerable  weight  and  has  become  steadily 
weaker. 

Status  prcBsens. — Urination  every  15  minutes,  painful,  hematuria  inter- 
mittent.   Emaciation  and  weakness. 

Examination. — The  patient  is  thin  and  anemic.  Chest  and  abdomen  not 
noted.  The  genitalia  are  negative  except  for  a  small  cyst  in  the  left  epidi- 
dymis. 


An  Operation  for  Cancer  of  Prostate.  585 

Rectal. — The  prostate  is  enlarged,  symmetrical,  smooth,  and  very  hard. 
It  projects  considerably  towards  the  rectum  and  the  upper  end  cannot  be 
reached.    The  prostate  is  extremely  tender. 

(No  notes  as  to  the  condition  of  the  seminal  vesicles.) 

Instrumental. — A  silver  catheter  passes,  but  the  outer  portion  has  to  be 
depressed  in  order  to  lift  it  over  a  median  prostatic  enlargement.  No 
note  as  to  residual  urine.  The  bladder  is  very  small,  and  irrigation  pro- 
duces hemorrhage. 

Urinalysis. — Bloody,  acid.  Microscopically  blood  corpuscles  and  epithel- 
ium. 

Operation,  September  15,  1900. — Mitchell.  Ether.  Suprapubic  cystos- 
tomy,  partial  excision  of  tumor  of  the  bladder.  Suprapubic  and  urethral 
drainage.  A  large  intravesical  tumor  involving  the  anterior  and  right 
lateral  walls  of  the  bladder  was  found.  The  median  portion  of  the  prostate 
was  not  enlarged,  and  no  note  of  any  involvement  of  the  base  of  the 
bladder  was  made.  The  tumor  was  curetted,  but  no  attempt  was  made 
to  excise  it  completely. 

Convalescence. — The  patient  suffered  considerably  from  pain  after  the 
operation,  and  it  was  impossible  to  wear  a  drainage  apparatus  owing  to 
hemorrhage  and  pain.  He  was  discharged  on  the  31st  day,  wearing  a 
catheter  in  the  urethra  and  leaking  through  the  suprapubic  wound. 

Case  27. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  two 
years.    Pain  and  frequency  of  urination.     SuprapuMc  cystostomy.    Death. 

S.  N.  17,555.    K.  H.,  age  60,  married,  admitted  April  1,  1905. 

Gonorrhoea  in  youth.  "^ 

Onset  two  years  ago  with  frequency  of  urination.  This  gradually  in- 
creased until  two  weeks  ago,  when  he  was  voiding  about  every  10  minutes. 
For  the  last  few  weeks  he  has  had  great  pain  in  the  suprapubic  region. 
No  history  of  complete  retention.  No  hematuria  except  that  following  an 
attempt  at  catheterization. 

Examination. — A  fairly  well  nourished  man  with  mucous  membranes  of 
fair  color.  Chest  and  abdomen  negative.  No  note  as  to  glandular  enlarge- 
ment. Hemoglobin  85  per  cent.  On  admission  the  patient  was  having 
great  difficulty  in  voiding;  only  a  small  quantity  being  passed  at  a  time. 
The  fundus  of  the  bladder  was  midway  between  symphysis  and  umbilicus 
and  a  catheter  drew  off  850  cc.  residual  urine.  Catheterization  caused 
rather  profuse  bleeding. 

Rectal. — Prostate  very  large  and  hard,  the  finger  being  unable  to  reach 
the  upper  limit.  Laterally  the  induration  extended  along  the  lateral  walls 
of  the  pelvis.     The  prostate  is  very  hard  and  of  uniform  consistency. 

A  suprapubic  cystostomy  was  done.  Palpation  of  the  prostate  through 
the  wound  showed  it  to  be  very  hard  though  there  were  no  intravesical 
projections  of  any  size.  Following  the  operation,  patient's  condition  grad- 
ually became  weaker  and  he  died  about  one  week  later.  No  autopsy 
obtained. 


586  Hugli  E.  Young. 

Case  28. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  five 
years.  Frequency  of  urination,  no  pain,  no  hemorrhage.  SuprapuMc 
cystostomy.    Improved. 

No.  1097.    E.  S.  H.,  age  61,  married,  admitted  November  11,  1905. 

Complaint. — "  Prostatic  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  five  years  ago  with  slight  difficulty  and 
increased  frequency  of  urination.  He  suffered  no  pain  and  had  little  in- 
convenience until  February,  1903,  when  he  had  complete  retention  of  urine 
for  the  first  time  and  was  catheterized  with  great  difficulty.  After  cathet- 
erization for  three  weeks  he  was  able  to  void  naturally.  In  May,  1903, 
he  consulted  a  well  known  surgeon  in  Chicago,  who  diagnosed  prostatic 
hypertrophy  and  advised  the  use  of  the  catheter  once  daily.  During  the 
past  two  years  the  catheter  has  been  used  at  intervals  of  two  or  three 
weeks.  He  has  been  able  to  void  naturally  and  with  little  difficulty,  but 
with  increasing  frequency.  Occasionally  there  is  considerable  difficulty, 
and  he  then  passes  a  catheter  and  finds  about  two  ounces  of  residual 
urine.  Catheterization  is  always  difficult,  sometimes  causes  hemorrhage 
and  produces  great  soreness  of  the  urethra. 

S.  P. — Micturition  about  every  one  and  one-half  hours  every  night  and 
day.  No  apparent  obstruction  and  very  little  difficulty  of  urination.  No 
pain,  no  hemorrhage.  He  is  constipated  and  often  has  difficulty  in  defeca- 
tion, but  never  any  pain  in  rectum,  thigh,  and  perineum,  testicles,  groins 
or  hips.  His  general  health  has  been  excellent,  and  he  has  not  lost  weight. 
Sexual  powers  apparently  normal. 

Examination. — The  patient  is  a  fairly  strong  looking  man  with  lips  of 
good  color,  but  his  complexion  is  very  sallow.  Pulse  is  good,  and  the 
arteries  are  not  sclerotic. 

Chest  and  abdomen;  notes  lost. 

The  epididymis  is  indurated  on  both  sides  and  slightly  tender.  There 
are  no  glands  in  the  groin. 

Rectal. — The  prostate  is  considerably  enlarged  in  both  lateral  lobes. 
The  surface  is  smooth.  The  consistence  is  markedly  indurated.  In  the 
region  of  both  seminal  vesicles  there  is  an  indurated  mass  which  is 
continuous  with  the  prostate,  and  the  two  are  connected  by  a  wide  plateau 
of  intravesicular  induration  the  upper  end  of  which  cannot  be  reached. 
On  the  right  side  the  induration  extends  upward  and  outward  along  the 
lateral  wall  of  the  pelvis,  and  the  surface  is  nodular.  No  enlarged  glands 
are  to  be  felt.  The  rectal  mucosa  is  soft  and  not  adherent,  but  the 
prostate  is  apparently  adherent  to  the  musculosa.  The  rectum  is  greatly 
diminished  by  the  prostate  which  projects  far  back  towards  the  sacrum 
leaving  but  little  passage  way.  The  prostate  is  not  very  tender,  and  is  not 
of  stony  hardness,  but  it  is  much  firmer  and  much  more  fixed  than  a 
benign  hypertrophy.  After  examination  there  was  an  escape  of  pus  from 
the  meatus,  but  examination  showed  no  bacteria. 

Diagnosis. — Inoperable  carcinoma  of  the  prostate  and  seminal  vesicles. 
Catheterization  at  bed  time  advised. 


An  Operation  for  Cancer  of  Prostate.  587 

December  17,  1905.— TYie  patient  has  been  troubled  with  chills,  fever, 
and  sweating.  This  usually  occurs  he  says  after  an  accumulation  of  pus 
in  the  prostate  and  disappears  after  the  evacuation  of  the  pus.  Catheter- 
ization sometimes  causes  great  pain  and  hemorrhage,  at  other  times  his 
only  pain  is  located  in  the  neck  of  the  bladder,  and  is  relieved  by 
urination. 

March  27,  1905. — The  patient  has  been  troubled  considerably  with  chills 
and  fever  associated  with  accumulations  of  pus  in  the  prostate,  as  above 
described.  Urination  has  been  frequent,  but  not  very  difficult,  and 
catheterization  has  been  employed  but  seldom,  and  then  he  finds  only  a 
small  amount  of  residual  urine.    He  has  no  pain. 

He  has  kept  at  his  work,  but  has  been  considerably  prostrated  by  the 
intermittent  febrile  attacks,  and  insists  on  relief.  The  prostate  and  seminal 
vesicles  are  involved  in  a  very  extensive  carcinomatous  mass  which  ex- 
tends beyond  the  reach  of  the  finger.  Radical  operation  is  out  of  the 
question  and  the  patient  appears  too  weak  for  palliative  partial  prosta- 
tectomy.    Suprapubic  cystostomy  for  continuous  drainage  advised. 

March  28,  1905. — Operation.  Ether.  Suprapubic  cystostomy.  The  blad- 
der was  opened  through  a  very  small  incision  at  a  point  well  towards  the 
vertex.  (To  avoid  impingement  of  tube  against  prostate.)  Examination 
of  the  bladder  with  the  finger  showed  a  small  median  bar,  with  a  small 
slightly  rounded  median  lobe,  behind  which  was  quite  a  deep  pouch. 
The  lateral  lobes  were  not  intravesically  enlarged.  There  was  no  intra- 
vesical tumor,  no  evidence  of  infiltration  of  the  bladder  wall.  The  vesical 
cavity  was  large.  There  was  very  little  trabeculation  and  no  stone. 
A  large  rubber  tube  was  introduced  and  the  bladder  firmly  closed  around 
it  with  catgut.  The  recti  muscles  were  approximated  with  catgut  leaving 
a  small  area  for  drainage. 

Convalescence. — The  patient  reacted  well  from  the  operation  and  the 
convalescence  was  uneventful.  At  the  end  of  a  month,  a  Bloodgood  drain- 
age apparatus  was  provided.  For  a  time  there  was  considerable  leakage, 
but  when  the  patient  left  the  hospital,  about  two  months  after  the 
operation,  the  apparatus  worked  fairly  well. 

June  16,  1906. — The  patient  is  in  excellent  health.  The  drainage  appar- 
atus works  well  and  gives  him  very  little  pain.  He  still  suffers  pain 
during  defacation  in  front  of  the  rectum  and  region  of  the  prostate.  The 
suppurative  condition  of  the  prostatic  urethra  has  subsided  and  the 
patient's  condition  is  much  improved  by  the  operation,  but  he  finds  the 
apparatus  disagreeable  to  wear. 

G.     Pekineal  Drainage,  Two  Cases. 

In  two  eases  median  perineal  urethrotom}'  was  performed,  in  one 
case  on  account  of  abscess  of  the  prostate  involving  the  perineum,  and 
in  the  second  case  on  account  of  the  inability  of  the  patient's  physician 
to  pass  a  catheter,  complete  retention  of  urine  being  present.     It  is 


588  Hugli  H.  Young. 

interesting  to  note  that  the  physician  reported  that  he  found  a  strict- 
ure of  the  deep  urethra,  a  condition  which  we  have  shown  is  fre- 
quently produced  b}'  carcinomatous  involvement  around  the  mem- 
branous and  prostatic  urethra. 

Except  in  suppurative  conditions  such  as  Case  Xo.  29,  perineal 
urethrotomy  has  little  to  commend  it.     These  two  cases  are  as  follows : 

Case  29. — Carcinoma  of  prostate  involving  perineum.  Abscess.  Perineal 
incision.     Death.    Autopsy. 

S.  N.  8610.    J.  R.,  age  56,  married,  admitted  February,  1899. 

Onset  two  years  ago  with  sudden  complete  retention  of  urine.  After 
dilatation  of  stricture  patient  had  no  further  trouble  until  July,  1898, 
when  he  noticed  a  pain  in  the  penis  and  passed  a  little  blood.  About 
one  month  later  received  a  blow  on  the  perineum  and  following  there  was 
a  slight  urethral  hemorrhage.  After  this  perineum  gradually  began  to 
swell  and  on  account  of  the  pain  he  was  obliged  to  go  to  bed.  Perineum 
finally  ulcerated  and  he  now  passes  urine  through  fistula.  Has  failed  a 
great  deal  in  general  health. 

General  examination. — Rather  poorly  nourished  man.  Quite  weak  and 
feeble  looking.  Considerable  emaciation.  ^Mucous  membranes  pale.  Xo 
general  glandular  enlargement.  Behind  the  scrotum  is  a  cauliflower  like 
mass  presenting  three  distinct  projections  and  in  the  center  is  a  urinary 
fistula.  A  hard  induration  fills  up  the  scrotum  and  the  testicles  are 
difficult  to  make  out. 

Operation. — An  incision  in  the  median  line  of  the  scrotum  opened  up 
a  mass  of  friable  tissue  which  encircled  urethra.  This  tissue  extended 
well  down  towards  rectum  and  pushed  the  testicle  forward.  Urethra  was 
very  friable  and  replaced  by  this  same  tissue.  Nothing  could  be  passed 
into  the  bladder.  Rectal  examination  showed  a  prostate  very  much  en- 
larged and  nodular,  especially  the  right  lobe.  The  friable  tissue  extended 
well  down  to  the  prostate. 

Patient  died  about  a  month  later. 

Autopsy. — On  the  pelvic  peritoneum  in  the  rectal  vesical  portion  and  upon 
several  loops  of  intestines  without  the  pelvic,  there  are  met  gray  elevations 
about  2  mm.  in  diameter.  The  whole  perineum  and  scrotum  and  a  large 
portion  is  the  site  of  a  very  foul  gangrenous  ulceration  extending  from 
the  margin  of  the  anus  to  the  most  interior  portion  of  the  scrotum  at  a 
distance  of  12  cm.  laterally  from  one  ischial  tuberosity  to  the  other.  The 
scrotum  is  in  a  great  part  transformed  to  a  dense  white  tissue  of  almost 
cartilaginous  consistence.  The  skin  is  firmly  fixed  upon  the  underlying 
mass. 

Bladder. — Mucous  membrane  is  intact.  Urethra  is  invaded  by  the 
perineal  ulceration  2  cm.  from  the  bladder;  it  is  completely  severed,  and 
for  a  considerable  distance  has  been  eaten  away  by  ulceration.  Lying 
below  the  base  of  the  bladder  between  it  and  the  rectum  is  a  mass  of  very 


An  Operation  for  Cancer  of  Prostate.  589 

dense  tissue  approximately  6  x  5i^  x  5  cm.  which  surrounds  the  seminal 
vesicles,  is  continuous  with  an  enlarged,  indurated  prostate,  and  the 
infiltration  in  the  perineum  and  scrotum.  The  recto-vesical  pouch  of 
peritoneum  is  indurated  and  nodular.  The  testicles  are  not  invaded  by 
the  growth.  The  inguinal  lymph  glands  show  metastases,  but  no  other 
than  the  inguinal  glands  involved.  Kidneys,  liver,  and  spleen  are  free. 
Microscopic  study  of  sections  from  diseased  areas  showed  adenocarcinoma. 

Microscopic  examination. — Numerous  sections  from  the  growth  and  its 
extensions  show  a  rather  cellular  carcinoma  with  a  loose  (Edematous 
stroma.  The  epithelium  is  distributed  irregularly  throughout  the  stroma, 
sometimes  occurring  in  good  sized  masses  with  very  little  intervening 
stroma,  and  again  slender  strands  of  cancer  cells,  infiltrating  in  between 
small  connective  tissue  bundles.  The  epithelium  is  polymorphus  in  shape, 
large  giant  cells  with  big  irregular  nuclei  being  frequently  encountered. 
In  areas  the  carcinoma  assumes  a  scirrhus  form,  cancer  cells  in  strands 
and  small  nests  being  scattered  here  and  there  with  rather  loose  abund- 
ant stroma.  There  is  noted  no  tendency  anywhere  to  the  formation  of 
acini.  Sections  made  from  the  skin  of  the  scrotum  which  was  involved 
in  the  growth  have  the  same  character  as  sections  from  the  primary  tumor 
mass,  viz.,  nests  of  irregular  cancer  cells  irregularly  distributed  in  a 
loose  stroma  frame-work. 

The  growth  is  a  carcinoma  simplex,  the  medullary  type  predominating. 

Case  30. — Cancer  of  prostate,  vesicles,  and  rectum.  Duration  one  year. 
Frequent  and  difficult  urination.  Previous  perineal  urethrotomy  "  for  stric- 
ture." 

No.  914.    T.  C.  P.  P.,  age  62,  married,  admitted  April  28,  1905. 

Onset  one  year  ago  with  slight  difficulty  in  urination  and  slight  increase 
in  frequency.  The  urinary  difficulty  and  frequency  gradually  increased 
until  he  urinated  every  15  minutes  night  and  day.  About  five  months  ago 
had  complete  retention  of  urine  and  as  considerable  difficulty  was  ex- 
perienced in  catheterizing,  a  perineal  section  was  performed.  A  finger 
passed  into  the  bladder  at  the  time  found  no  intravesical  enlargement, 
but  there  was  marked  constriction  of  the  entire  urethra.  After  that  the 
patient  was  considerably  improved  and  was  able  to  void  fairly  well  through 
the  urethra.  After  several  weeks  he  began  to  suffer  with  severe  pain  in 
hips,  particularly  on  right  side  and  running  down  legs.  Fistula  had  to 
be  dilated  a  few  weeks  ago  and  on  passing  a  finger  into  the  bladder  there 
was  found  a  small  intravesical  nodule  growing  on  the  right  side.  This  was 
not  present  before. 

S.  P. — Continuous  dribbling  through  the  fistula — only  occasionally 
through  penis.  Six  months  ago  had  some  pain  in  rectum  but  this  is  very 
slight  now.  Considerable  pain  in  hips  and  legs,  along  the  course  of  the 
sciatic  nerves. 

General  examination. — Patient  very  weak  and  emaciated. 

Rectal. — About  one  inch  distant  from  the  anal  margin  the  anterior 
wall  of  the  rectum  is  thrown  into  a  high  transverse  fold  which  is  com- 


590  Hugh  E.  Young. 

posed  of  very  much  indurated  tissue  and  apparently  continuous  with  a 
markedly  indurated  prostate  beneath.  About  one  inch  higher  up  on  the 
right  lateral  wall  of  the  rectum  is  a  roughened  irregular  area  about 
2  to  3  cm.  in  diameter,  this  area  gives  the  sensation  of  rough  irregular 
granulations  upon  the  surface  of  the  mucous  membrane.  It  is  difl&cult 
to  make  out  the  exact  outlines  of  the  prostate,  but  it  is  considerably 
enlarged,  irregular  in  shape,  very  hard,  and  generally  closely  adherent  to 
the  rectum.  On  the  left  side  it  is  firmly  attached  to  lateral  structures  of 
the  pelvis,  and  seems  to  extend  well  up  into  the  region  of  the  seminal 
vesicle.  On  the  right  side  the  enlargement  is  smaller,  but  there  is  definite 
induration  running  up  into  the  region  of  the  seminal  vesicle.  On  the 
posterior  wall  of  the  rectum  in  front  of  the  sacrum  an  enlarged  gland  about 
1  cm.  is  felt.  The  upper  border  of  the  prostatic  mass  presents  a  concave 
shape  (evidently  an  intravesicular  mass),  above  which  a  soft  bladder  can 
be  felt. 
No  operation  was  advised. 

H.     Treated  by  CATHETERizATioisr,  16  Cases. 

Seven  of  these  cases  had  complete  retention  of  urine  and  led 
catheter  lives  before  entering  the  hospital  for  various  periods  (6  weeks, 
two  cases;  6,  9,  10  and  11  months,  and  3  years,  each  one  case).  In 
one  case  the  catheter  had  been  used  4  months  on  account  of  a  large 
residual  urine.  Two  cases  had  used  a  catheter  occasionally  on  account 
of  complete  retention  of  urine.  Six  cases  had  never  been  catheterized 
before  entrance  to  the  hospital,  but  all  of  the  16  cases  required 
catheterization  after  leaving  the  hospital  with  the  exception  of  Case 
45,  which  required  catheterization  for  six  weeks  during  an  attack  of 
acute  gonorrhoea  (and  the  patient  aged  76!),  after  the  disappearance 
of  the  acute  symptoms  of  urethritis  voluntary  urination  returned,  and 
Case  39,  who  died  soon  after  leaving  the  hospital. 

In  six  cases  catheterization  was  apparently  entirely  satisfactory.  In 
three  cases  no  note  has  been  made  and  in  the  other  cases  catheteriza- 
tion is  very  difficult  and  painful,  but  no  subsequent  operation  has  been 
necessary  as  far  as  I  can  learn. 

Ten  of  these  sixteen  cases  have  died,  all  within  a  year  after  leaving 
the  hospital.  Four  cases  are  still  alive  and  comfortable  with  the  ex- 
ception of  pain  in  the  back  and  thighs,  and  one  does  not  use  the 
catheter. 

A  review  of  these  cases  shows  that  the  catheter  is  quite  successful  in 
a  fair  number  of  cases.  As  a  rule  a  soft  rubber  Nelaton  catheter  has 
been  employed,  and  has  usually  been  found  to  enter  more  easily  than 


An  Operation  for  Cancer  of  Prostate.  591 

a  coude  catheter,  owing  to  the  fact  the  obstruction  is  due  to  a  circular 
constriction  of  the  urethra  and  not  as  a  rule  to  marked  median  lobe 
formation. 

Where  catheterization  is  very  difficult  or  painful  or  produces  con- 
siderable irritation  and  suppuration  some  palliative  operation,  is,  as 
a  rule,  preferable.  The  histories  in  which  a  catheter  was  employed  is 
as  follows: 

Case  31. — Carcinoma  involving  prostate,  seminal  vesicles,  and  pelvic 
glands.  Duration  15  months.  No  pain,  no  hematuria.  Advised  to  use 
catheter. 

S.  N.   9438.     McK.  C,  age  67,  married,  admitted  September,  1899. 

No  history  of  gonorrhoea. 

Onset  15  months  ago,  with  increased  frequency  of  urination.  Some 
months  later  began  to  have  some  difficulty  in  passing  water  and  some 
hesitation.  Never  passed  any  gravel.  No  hematuria.  Condition  gradually 
became  worse  until  six  months  ago,  when  he  had  complete  retention. 
A  catheter  was  passed  with  considerable  difficulty.  For  the  past  six 
months  he  has  been  unable  to  void  voluntarily  and  catheterizes  him- 
self about  eight  times  in  24  hours.     No  pain  noted.     Has  lost  40  pounds. 

Examination. — Patient  is  fairly  well  nourished  man.  Chest  and  abdo- 
men negative.     No   glandular   enlargement. 

Rectal  examination. — The  prostate  is  found  to  be  much  enlarged,  very 
hard,  firm,  rough  and  nodular,  projecting  further  backward  on  the  left 
side.  Beneath  the  mucosa  can  be  felt  several  small,  freely  movable,  hard, 
round  bodies,  presumably  glands.  These  are  directly  over  the  surface  of 
the  enlarged  prostate.     The  greatest  enlargement  is  over  the  left  side. 

The  urine  is  cloudy  with  pus;  Sp.  gr.  1019;  faintly  acid — no  sugar;  a 
faint  trace  of  albumin. 

Advised  to  use  catheter. 

Case  32. — Carcinoma  of  the  prostate,  seminal  vesicles  and  pelvic  struc- 
tures. Duration  two  years.  Marked  constipation,  difflculty  of  urination, 
pain  in  the  abdom,en.     No  operation. 

S.  No.  12401.     R.  L.,  age  56,  married,  admitted  September  25,  1901. 

Complaint. — "  Bowel  and  kidney  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  two  years  ago  with  difficulty  in  urinating,  and 
intermittent  stoppage  and  straining  during  urination  associated  with 
pain  above  the  symphysis.  During  the  past  two  years  this  condition 
has  persisted,  and  constipation  has  been  present  and  gradually  become 
worse.     During  the  past  six  weeks  he  has  had  mucus  in  stool. 

Examination.— The  patient  is  a  sparely  built  man  with  lips  of  fair  color. 
There  are  numerous  areas  of  pigmentation  in  the  skin  in  various  parts 
of  the  body.  The  heart  and  lungs  are  negative.  The  abdomen  is  promi- 
nent in  the  hypogastric  region  and  many  coils  of  intestine  are  visible. 
Enlarged  glands  are  present  in  both  groins. 


593  Hugh  H.  Young. 

Rectal. — In  the  region  of  the  prostate  is  a  firm  nodular  mass  which 
extends  upward  beyond  the  reach  of  the  finger,  and  almost  blocks  the 
rectum.  Laterally  it  is  attached  to  the  walls  of  the  pelvis  and  is  im- 
movable. On  its  surface  are  numerous  indurated  ridges.  The  rectal  mucosa 
is  freely  movable  and  soft.     No  enlarged  glands  are  noted. 

Urinalysis. — Cloudy,  1010,  acid,  no  sugar,  no  albumin.  Microscopically 
squamous  epithelial  cells  and  a  few  pus  cells. 

Cystoscopy  not  performed.  No  urethral  examination.  No  note  as  to 
the  frequency  of  urination. 

Remark. — The  history  is  unfortunately  incomplete,  but  it  is  evident  that 
the  patient  complained  largely  of  obstruction  to  the  bowels.  He  was 
treated  by  purgatives  and  enemata,  and  was  improved.  No  operation 
was  performed. 

April  12,  1906. — Letter  from  wife.  "  After  returning  home  his  feet  and 
legs  were  swelled,  urination  was  no  more  difficult,  but  catheterization  was 
necessary  all  the  time.  He  suffered  pain  in  the  lower  part  of  the  stomach. 
There  was  chronic  constipation  and  enemata  were  necessary.  No  operation 
was  performed.  Before  death  he  suffered  all  the  time  and  could  not 
retain  anything.     Death  occurred  four  years  ago." 

Case  33. — Carcinoma  of  prostate  and  seminal  vesicles  with  intravesical 
lobules.  Duration  10  years  (?)  Symptoms:  Frequency  of  urination,  loss 
of  weight.    No  operation. 

S.  N.  13,638.    H.  C.  C,  age  60,  admitted  July  23,  1902. 

Onset  with  frequency  of  urination  and  hesitation.  Frequency  gradually 
increased  until  he  was  voiding  from  two  to  six  times  at  night,  and  only 
relieved  himself  after  considerable  straining.  About  six  weeks  ago  was 
passing  urine  every  20  minutes  and  complete  retention  of  urine  came  on 
and  he  had  to  be  catheterized.  After  being  catheterized  for  some  time 
he  was  able  to  void  voluntarily.  No  pain  except  some  burning  on  urina- 
tion.    Has  lost  30  pounds  in  the  last  few  months. 

S.  P. — Urination  every  two  hours,  accompanied  by  a  slight  burning  in 
urethra.    No  hematuria. 

Examination. — Very  anemic,  weak,  sick-looking  man.  Mucous  mem- 
branes pale.  Chest  negative.  Abdomen  negative,  except  that  distended 
bladder  can  be  felt  above  the  symphysis. 

Rectal  examination. — Prostate  moderately  enlarged,  contour  irregular, 
distorted  and  composed  of  irregular  lobules  in  places  of  considerable  in- 
duration. Right  lobe  larger  than  left.  Median  furrow  and  notch  are 
obliterated,  and  the  bases  of  both  seminal  vesicles  are  involved  in  indura- 
tion.    Catheter  readily  passed  and  540  cc.  of  urine  removed. 

Cystoscopic  examination. — Study  of  the  prostatic  orifice  shows  very 
irregular  intravesicular  outgrowth  of  the  prostate.  There  are  many 
deep  clefts  in  between  lobulated  outgrowths.  In  some  places,  especially 
the  left  side  and  above,  these  are  frayed  out  and  are  quite  suggestive  of 
new  growth.  In  places  they  are  covered  with  fibrin  and  it  is  therefore 
impossible  to  make  a  positive  diagnosis  as  to  malignancy.     The  bladder 


An  Operation  for  Cancer  of  Prostate.  593 

wall  contains  no  neoplasm.  With  the  finger  in  the  rectum  and  cystoscope 
in  urethra  a  prostatic  collar  about  three-fourths  of  an  inch  thick  is  felt 
around  the  cystoscope.  The  lateral  lobes  are  not  markedly  enlarged,  but 
are  hard.  Urine  contains  a  large  amount  of  pus.  No  operation  advised 
on  account  of  weak  condition  of  patient.  Instructed  to  use  catheter,  which 
he  did  four  times  a  day.     The  patient  died  five  days  after  leaving  hospital. 

Case  34. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  three 
years.    Frequency  and  difficulty  of  urination.    Little  pain.    No  operation. 

S.  N.  15,327.     S.  O.,  age  59,  married,  admitted  October  18,  1903. 

Onset  three  years  ago  with  some  difficulty  in  voiding.  Since  then 
condition  has  gradually  grown  worse — urination  has  increased  until  it  is 
now  15  to  20  times  during  the  day  and  at  night  every  half  hour.  Up 
to  six  months  ago  frequency  not  marked.  For  the  last  six  months  has 
had  some  pain  on  passing  urine,  but  at  no  other  time.  Has  lost  30  pounds 
in  weight  during  the  last  seven  months. 

S.  P. — Pain  on  urination;  increased  frequency — 15  to  20  times  during 
day — every  half  hour  at  night — loss  in  weight.  No  note  as  to  retention 
or  hematuria.  Does  not  catheterize  himself.  No  physical  examination 
recorded. 

Rectal  examination. — The  prostate  is  considerably  enlarged  in  both 
lateral  lobes,  contour  irregular,  nodular  and  very  hard.  The  region  of 
the  right  seminal  vesicle  is  indurated  and  adherent  to  the  prostate.  The 
left  seminal  vesicle  is  apparently  not  involved.  The  mucous  membrane  of 
the  rectum  is  soft  and  not  adherent.  No  glands  are  to  be  felt.  The  pros- 
tate presents  well  into  the  rectum. 

Gystoscopic  examination. — Shows  an  irregular  mass  projecting  around 
the  orifice  of  the  prostate  on  the  left  side.  The  surface  of  this  is  irregular 
and  the  mass  extends  considerably  into  the  bladder  and  is  about  3  cm.  in 
diameter.  The  rest  of  the  prostatic  orifice  is  apparently  normal.  The 
mucous  membrane  of  the  bladder  is  markedly  inflamed.  The  ureters 
are  easily  seen.  Urine  cloudy.  Sp.  gr.  1010  acid;  trace  of  albumin,  num- 
erous cells;  no  sugar;  urea,  24  grams  to  liter.     Diagnosis:  carcinoma. 

Patient  advised  to  use  catheter  regularly. 

April  12,  1906. — Letter.  "  The  course  of  the  disease  after  returning  home 
was  rapid.  Urination  was  more  difficult  and  catheterization  necessary 
five  or  six  times  a  day.  He  suffered  pain  in  the  back,  abdomen,  and 
rectum.  Blood  was  frequently  present  in  the  urine,  there  was  considerable 
loss  of  weight,  and  chronic  constipation.  No  operation  was  necessary, 
and  the  patient  died  three  months  after  returning  from  the  hospital." 

Case  35. — Carcinoma  of  prostate.  Duration  of  symptoms  eight  months. 
Catheterism.    Loss  of  weight.    No  operation.    Death  ten  days  later. 

S.  N.  16,033.     D.  S.,  age  65,  married,  admitted  April  24,  1904. 

No  history  of  gonorrhoea. 

Symptoms  of  onset. — Increased  frequency  of  urination  and  considerable 
straining.     The  straining  and  frequency  of  urination  have  gradually  in- 


594  Hugli  H.  Young. 

creased.  No  note  as  to  pain  or  hematuria.  The  patient  has  gradually 
lost  weight — about  20  pounds.  He  has  been  using  a  catheter  at  inter- 
vals for  the  past  six  months,  and  of  late  has  been  using  it  regularly. 

Examination. — The  patient  is  much  emaciated  and  his  mucous  mem- 
branes are  pale.  Chest  negative.  Abdomen  negative,  with  exception  of 
tenderness  in  the  suprapubic  region,  and  also  in  both  iliac  fossae.  No 
note  as  to  glandular  enlargement.  A  silver  prostatic  catheter  passes 
with  slight  difficulty,  the  beak  being  lifted  by  a  median  lobe.  180  cc. 
residual  urine  was  obtained.  The  bladder  would  hold  only  180  cc.  of  irri- 
gating fluid. 

Rectal. — The  lateral  lobes  of  the  prostate  are  slightly  hypertrophied,  but 
hard  and  nodular.  The  median  furrow  is  present.  No  note  is  recorded 
as  to  the  seminal  vesicles,  and  the  history  otherwise  is  incomplete,  but 
there  was  no  doubt  expressed  as  to  the  diagnosis  of  carcinoma. 

Urine  cloudy  from  pus.  Sp.  gr.  1010,  alkaline,  albumin  present,  a  few 
granular  casts. 

The  patient  was  treated  by  permanent  catheter  and  bladder  irrigation, 
but  gradually  became  weaker  and  died  ten  days  after  admission.  No 
autopsy. 

Case  36. — Carcinoma  of  the  prostate  and  seminal  vesicles.  Duration 
one  and  a  half  years.     Catheter  life.    No  operation.    Death  within  a  year. 

No.  670.     Wm.  G.,  age  69,  admitted  July,  1904. 

Onset  with  frequency  and  slight  difficulty  in  urination.  No  pain.  Fre- 
quency and  difficulty  gradually  increased  until  about  11  months  ago,  when 
he  had  complete  retention  and  had  to  be  catheterized.  Since  then  has 
used  the  catheter  regularly,  being  unable  to  void  naturally,  and  he  has 
used  the  catheter  about  every  three  or  four  hours.  During  the  past  six 
months  hemorrhages  have  been  very  frequent  and  quite  severe,  although 
a  soft  rubber  catheter  is  used. 

8.  P. — Uses  catheter  every  two  hours,  night  and  day.  No  pain  except 
on  introduction  of  catheter.  Has  lost  about  15  pounds  in  the  past  year. 
General  health  pretty  good. 

Examination. — A  fairly  strong  looking  man.  Lips  and  mucous  mem- 
branes of  good  color.    Arteries  very  sclerotic. 

Rectal  examination. — Prostate  bulges  far  towards  rectum.  It  is  irregu- 
lar in  places,  nodular,  and  extends  far  out  on  each  side.  The  induration 
runs  up  in  the  region  of  the  seminal  vesicles  beyond  the  reach  of  the  finger 
along  the  lateral  walls  of  the  pelvis.  The  upper  edge  of  the  prostate  can 
be  reached  with  difficulty  in  the  median  line,  and  on  each  side  the  limits 
cannot  be  made  out.  The  rectal  wall  is  closely  adherent  to  the  prostate. 
The  consistence  of  the  prostate  is  extremely  hard  in  most  places,  though 
small,  soft  areas  can  be  felt.  No  definite,  large  glands  are  to  be  made 
out,  but  in  the  region  of  the  seminal  vesicles  several  irregular  cords  of 
induration,  probably  lymphatics  can  be  felt.  The  patient  was  advised  to 
continue  catheter  life. 

The  patient  died  March  26,  1905.     He  had  much  pain  in  the  region  of 


An  Operation  for  Cancer  of  Prostate.  595 

the  prostate,  and  in  the  legs.  He  used  a  catheter  successfully  until  four 
days  before  his  death.  Catheterization  then  became  very  difficult  and 
considerable  hemorrhage  was  produced  by  his  physician  in  using  catheters. 

Case  37. — Carcinoina  of  prostate  and  seminal  vesicles.  Duration  ten 
months.    Pain  and  frequency  of  urination.    No  operation.     Catheter  life. 

S.  N.  16,579.     E.  A.  H.,  age  57,  married,  admitted  August  24,  1904. 

No  history  of  gonorrhcea. 

Onset  with  burning  pain  in  rectum.  This  recurred  at  irregular  intervals, 
but  with  gradually  increasing  intensity.  About  two  months  after  onset 
patient  developed  pain  in  penis,  scrotum  and  perineum  which  at  first  was 
intermittent  but  now  is  a  continuous,  dull  ache.  He  began  to  get  up  once 
at  night  to  urinate  two  months  ago,  but  had  very  little  urinary  disturb- 
ance. Since  then  he  has  had  tingling  pains  along  the  course  of  both 
sciatic  nerves,  has  lost  about  20  pounds  in  weight,  but  has  not  had 
hematuria  nor  acute  retention  of  urine. 

S.  P. — Pain  in  rectum,  penis,  scrotum,  perineum,  tingling  sensations 
along  the  course  of  both  sciatic  nerves.  But  slight  urinary  symptoms.  No 
hematuria  or  catheterism.     General  health  fairly  good. 

Examination.— A  poorly  nourished  man,  with  mucous  membranes  of 
poor  color.  Chest  and  abdomen  negative.  Several  small,  hard  glands  are 
palpable  in  the  left  groin,  and*  a  few  softer  glands  in  the  right  groin.  No 
other  glandular  enlargement.  On  rough  examination  slight  impairment 
of  sensation  of  touch  on  right  thigh  in  a  limited  area,  including  slight  por- 
tion of  perineum  and  extending  about  one-third  the  distance  of  thigh 
toward  knee  on  its  internal  aspect. 

Rectal  examination. — Shows  a  hard,  nodular  prostate,  the  size  of  one's 
fist.  The  right  lobe  is  somewhat  larger  than  the  left  and  extends  well 
over  against  the  pelvis.  The  left  is  not  so  closely  attached  to  the  pelvis. 
The  median  furrow  is  obliterated  by  an  intravesicular  mass,  the  upper 
edge  of  which  is  very  sharp.  The  seminal  vesicles  are  involved  in  the 
induration.  Several  small,  movable,  hard  nodules  are  felt  on  surface 
of  the  gland.  A  catheter  is  introduced  without  much  difficulty  and  500 
cc.  residual  urine  obtained. 

,  Cystoscopic  examination. — Slight  enlargement  of  median  portion  of  pros- 
tate. No  lateral  enlargements  shown.  With  finger  in  rectum  and  cysto- 
scope  in  urethra  instrument  is  found  to  be  surrounded  by  a  hard  nodular 
mass,  and  the  beak  is  difficult  to  feel.  Urine,  cloudy  from  pus.  Sp.  gr. 
1012;  acid,  no  sugar;  trace  of  albumin.  The  patient  was  advised  to  use  a 
catheter. 

April  12,  1906. — Letter.  "  The  course  of  the  disease  after  returning  home 
was  rapidly  fatal.  Urination  was  not  much  more  difficult  and  catheteri- 
zation necessary  twice  a  day,  for  a  while,  but  none  at  all  for  a  month  before 
death.  The  patient  suffered  pain  in  the  pelvic  region  and  down  the  inside 
of  the  thighs.  There  was  no  hematuria;  he  lost  weight  steadily;  there  was 
constipation  and  rectal  trouble.    He  died  April  3,  1905." 


596  Hugh  H.  Young. 

Case  38. — Carcinoma  of  prostate,  left  seminal  vesicle  and  pelvic  glands. 
Duration,  two  and  a  half  years.  Symptoms:  Frequency  of  urination; 
no  pain;  no  blood;  no  operation. 

No.  742.     J.  H.  D.,  age  67,  married,  admitted  October,  1904. 

Onset  with  frequency  and  precipitancy.  This  frequency  has  gradually 
increased  until  now  he  voids  about  every  hour  at  night  and  every  one 
to  two  hours  during  the  day.  No  hematuria.  He  has  been  catheterized 
regularly  for  the  past  four  months  about  twice  a  day;  has  lost  no  weight 
in  the  last  few  months  and  feels  better  than  he  has  in  a  year.  No  pain 
except  a  little  at  the  beginning  of  urination. 

S.  P. — Catheterism  twice  daily  on  account  of  large  residual.  No  pain 
present. 

Examination. — The  patient  is  well  nourished,  and  the  mucous  mem- 
branes are  of  good  color. 

Rectal. — The  prostate  is  enlarged  more  so  in  the  left  than  the  right  lobe. 
The  median  furrow  is  present,  but  the  notch  is  shallow  and  just  above 
it  is  a  slight  ledge,  especially  on  the  left  side,  which  is  quite  hard.  The 
right  lobe  of  the  prostate  is  very  hard  and  has  in  its  midst  a  globular 
mass  about  the  size  of  a  cherry,  which  is  quite  hard.  The  left  lobe  of 
the  prostate  is  larger  than  the  right  and  is  continuous  with  an  indurated 
mass,  which  extends  upwards  in  the  region  of  the  left  seminal  vesicle. 
The  left  lobe  and  the  mass  above  described  are  very  hard  and  somewhat 
irregular.  Along  the  surface  of  the  mass  above  the  prostate  near  its 
inner  border  a  hard  cord  is  to  be  felt.  By  turning  the  finger  outward 
and  then  backward  and  inserting  it  as  far  as  possible  one  can  follow  an 
indurated  line  of  tissue,  probably  a  lymphatic,  and  feel  one  enlarged 
gland.  The  region  of  the  right  seminal  vesicle  is  very  little  enlarged, 
but  one  or  two  hard  cords  are  to  be  felt.  Residual  urine,  about  200  cc. 
is  present. 

Cystoscopic  examination. — The  bladder  is  considerably  trabeculated. 
There  is  a  slight  cystitis.  A  marked  hypertrophy  of  the  trigone  is  present. 
There  is  a  definite  enlargement  of  the  median  portion  of  the  prostate  in 
the  shape  of  a  narrow  transverse  bar,  which  is  continuous  with  the  two 
lateral  lobes,  which  are  also  slightly  more  prominent  than  normal;  but 
there  are  no  clefts  between  them.  With  cystoscope  in  urethra  and  finger 
in  rectum  it  is  impossible  to  feel  the  beak,  owing  to  the  great  thickness 
in  the  median  portion  of  the  prostate.  Urine  cloudy  from  pus.  Advised 
to  use  catheter. 

In  April,  1905,  the  patient  had  lost  a  great  deal  of  weight  and  strength. 
Had  also  considerable  pains  in  legs  along  sciatic  nerves  and  around  knees, 
especially  on  the  left  side. 

April  12,  1906. — Letter.  "  After  returning  home  the  course  of  the  disease 
was  progressively  downward.  Urination  was  at  times  attended  with 
more  pain  and  catheterization  was  necessary  every  three  to  five  hours. 
The  pain  was  in  the  form  of  sciatica  and  in  the  region  of  the  second 
lumbar  vertebrae.  Hematuria  occurred  six  times.  There  was  very  great 
loss  of  weight  and  chronic  constipation.  No  operation  was  necessary. 
The  patient  died  August  11,  1905,  of  uremia." 


An  Operation  for  Cancer  of  Prostate.  597 

Case  39. — Carcinoma  of  prostate  and  seminal  vesicle.  Duration  one 
year.  Severe  pain  in  the  aidomen,  difficulty  and  frequency  of  urination. 
Sudden  death.    No  operation. 

S.  No.  17,199.    J.  N.,  age  57,  married,  admitted  January  2,  1905. 

Complaint. — "  Pain  in  stomach,  and  in  right  leg.     Diabetes." 

The  patient  had  gonorrhoea  at  the  age  of  18  years. 

Present  illness  began  about  one  year  ago  with  difficulty  in  urination 
and  pain  in  the  end  of  the  penis  at  the  end  of  urination.  Micturition  was 
quite  frequent  at  night.  On  July  18,  1904,  he  was  admitted  to  the  Medical 
Dispensary,  complaining  of  stomach  trouble,  but  the  physical  examination 
was  negative,  except  that  the  urine  was  cloudy  with  pus.  He  was  trans- 
ferred to  the  Genito-urinary  Dispensary,  where  the  following  notes  were 
made:  Patient  complained  of  pain  in  the  region  of  the  bladder  and 
the  right  groin,  frequency  of  urination  and  slight  straining  at  the  end. 
The  urine  contains  pus  and  numerous  bacilli.  The  prostate  is  slightly 
enlarged,  somewhat  nodular^  not  very  tender.  The  induration  extends 
along  the  seminal  vesicle  on  the  left  side,  and  in  the  tissue  between  the 
rectum  and  the  prostate  is  a  hard,  round  mass,  1  cm.  in  diameter,  freely 
movable.  The  diagnosis  of  chronic  prostatitis  was  made  and  he  was 
treated  by  massage.  After  one  month  his  condition  was  considerably 
improved.  He  was  asked  to  come  for  a  cystoscopy  but  failed  to  return, 
and  did  not  appear  again  at  the  hospital  until  January  2,  1905,  when  he 
was  admitted  complaining  of  pain  in  the  stomach  and  leg.  He  said  that 
he  had  been  troubled  considerably  with  frequency  of  urination,  often 
having  to  urinate  12  times  during  the  night,  and  at  times  catheterization 
has  been  necessary.  Of  late  he  has  been  suffering  with  a  severe  pain  in 
the  abdomen,  nausea  and  vomiting. 

Examination. — The  patient  is  well  nourished,  but  his  lips  are  pale.  The 
chest  is  negative. 

Abdomen. — The  bladder  is  considerably  distended,  reaching  the  umbili- 
cus. In  the  right  groin  are  numerous  hard  glands,  and  in  the  left  groin 
a  number  of  smaller  glands. 

Rectal. — The  prostate  is  very  much  enlarged.  The  right  lobe  extends 
over  to  the  bony  wall  of  the  pelvis  and  the  upper  margin  can  just  be 
reached.  It  does  not  bulge  towards  the  rectum,  is  extremely  hard,  nodu- 
lar. The  left  lobe  is  more  prominent  than  the  right  but  does  not  extend 
to  the  pelvic  wall.  The  lower  portion  is  soft  and  almost  fluctuates.  The 
upper  end  of  the  prostate  is  indurated  and  cannot  be  passed  by  the 
finger.     The  right  seminal  vesicle  is  much   enlarged,  hard  and  nodular. 

The  left  vesicle  is  not  palpable.  The  rectum  is  markedly  compressed 
by  the  prostatic  mass. 

Urinalysis. — Cloudy,  acid,  no  albumin,  no  sugar,  microscopically,  pus 
cells  and  epithelium  in  large  number. 

A  catheter  passes  with  ease  and  withdraws  450  cc.  residual  urine.  The 
diagnosis  of  an  inoperable  carcinoma  was  made.  He  remained  in  the 
hospital  for  14  days.  He  suffered  severely  from  abdominal  pain  and 
vomiting,  and  for  two  days  the  temperature  ranged  between  101°  and  104°. 
He  died  suddenly  January  16,  1905.    No  autopsy  could  be  obtained. 


598  Hugh  H.  Young. 

Case  40. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  two 
years.  Complete  retention  of  urine.  Severe  pains  in  buttocks  and  thighs. 
No  operation. 

J.  H.  H.  Surg.  No.  17,247.  A.  S.  R.  0.,  age  67,  married,  admitted  January 
13,  1905. 

Complaint. — "  Retention  of  urine.    Pain  in  legs." 

No  history  of  gonorrhoea. 

Present  illness  began  two  years  ago  with  frequency  of  urination  which 
gradually  increased  until  he  often  voided  urine  20  times  during  the  night. 
Six  months  ago  he  began  to  have  pain  in  the  buttocks,  and  posterior  aspect 
of  thighs,  legs,  ankles,  and  heels.  This  pain  was  of  a  dull  aching  character 
and  intermittent,  coming  on  every  three  or  four  days  and  lasting  several 
hours.  The  pain  was  worse  on  the  right  side  than  on  the  left.  Three 
weeks  ago  retention  of  urine  came  on  and  since  then  the  patient  has 
catheterized  himself  three  times  daily.  During  the  past  three  weeks  he 
has  also  had  weakness  of  his  anal  sphincter  and  involuntary  escape  of  feces 
associated  with  diarrhoea.  There  has  been  no  hematuria  and  no  calculus. 
He  has  lost  15  pounds  during  the  past  three  months. 

Examination. — The  patient  is  sallow  and  slightly  emaciated  and  pale. 
The  lungs  and  heart  are  negative.  The  liver  is  slightly  enlarged,  and  the 
bladder,  when  distended  reaches  to  within  2  cm.  of  the  umbilicus.  The 
genitalia  are  normal. 

Rectal. — The  mucosa  of  the  rectum  is  thrown  into  many  folds  and 
numerous  small  shot-like  bodies  are  felt  beneath  it.  The  prostate  is 
bilaterally  enlarged,  hard,  apparently  homogeneous  and  without  nodules. 
The  seminal  vesicles  are  enlarged,  firm,  but  not  very  hard,  and  are 
continuous  with  the  induration  of  the  upper  portion  of  the  prostatic  lobe 
on  each  side,  the  right  lobe  of  which  is  the  larger.  A  chain  of  hard 
glands  or  phleboliths  is  felt  along  the  seminal  vesicles  on  both  sides.  The 
rectal  mucosa  is  not  adherent,  there  is  no  tenderness,  the  membranous 
urethra  is  thickened  and  indurated. 

Sensations. — Analgesia  is  almost  complete  over  the  left  buttock,  the 
left  half  of  scrotum  and  left  half  of  penis.  Catheterization  is  accomplished 
with  very  little  sensation  to  the  patient.  Knee  jerks  poor.  Ankle  reflex 
absent.  Dartos  and  cremasteric  reflexes  active.  The  left  buttock  hangs 
lower  and  is  more  flabby  than  the  right  and  the  gluteus  on  that  side 
cannot  be  contracted. 

Cystoscopic. — Retention  of  urine  is  complete  and  the  catheter  finds  200  cc. 
of  urine.  The  cystoscope  shows  a  moderate  enlargement  of  both  lateral 
lobes  and  a  small  median  bar  connecting  the  two  lateral  lobes  without 
intervening  sulci.  The  mucous  membrane  is  everywhere  smooth  and  there 
is  no  evidence  of  intravesical  neoplasm.  The  bladder  is  slightly  trabe- 
culated  and  inflamed.    The  ureters  are  normal  in  appearance. 

Urinalysis. — Cloudy,  1020,  acid,  no  sugar,  albumin  a  trace.  Microscopic- 
ally pus  cells  and  bacilli. 

January  22. — Dr.  Thomas.  The  ankle  clonus  is  just  present  on  both 
sides.    Voluntary  movements  of  hip,  knees,  and  ankles  are  normal. 


An  Operation  for  Cancer  of  Prostate.  599 

Reflexes. — The  abdominal  reflexes  are  difficult  to  obtain,  but  are  present. 
The  measurements  of  both  limbs  are  about  the  same,  the  right  being  a  little 
larger.  Over  the  buttocks  on  both  sides  the  patient  feels  the  slightest 
touch  with  the  finger  or  a  camels-hair  brush.  With  the  hair  test  the  sense 
is  less  acute  over  the  left  buttocks,  but  on  the  right  side  the  answers  are 
accurate.  With  the  needle  point  the  answers  are  usually  appreciated  but 
less  active  on  left  side,  and  over  this  buttock  the  temperature  sense  is  also 
distributed,  no  distinction  being  made  between  hot  and  cold.  The  sensory 
disturbance  over  the  penis  and  scrotum  seems  to  be  more  over  the  penis 
and  scrotum  on  the  left  side. 

January  24- — Dr.  Gushing.  Patient  seems  to  be  improving.  The  subject- 
ive sensation  of  numbness  is  much  less.  The  electric  reaction  of  the 
muscles  are  normal.  Analgesia  is  almost  complete  over  the  left  buttock, 
left  half  of  scrotum  and  of  penis,  the  needle  being  recognized  as  a  hair 
and  a  hair  not  felt.  Cold  is  not  recognized,  and  warmth  but  faintly.  No 
anesthesia  can  be  detected  on  the  left  foot,  heel,  or  little  toe,  but  the 
thermic  sense  is  less  acute  than  on  the  right  side.  The  X-ray  show  that 
the  bony  outlines  in  the  sacral  region  are  suspiciously  indistinct  (probably 
malignant  involvement). 

Diagnosis. — Primary  cancer  of  prostate.  Intraspinal  tumor  of  the 
Cauda  equina?  Pressure  symptoms  of  fourth  and  fifth  sacral.  Crossed 
paraplegia? 

August,  1905. — The  physician  in  attendance  reports  that  the  patient 
died  from  cancer  of  the  prostate. 

Case  41. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  one 
year.  Symptoms:  Frequency  of  urination,  pain.  No  operation.  Catheter 
advised. 

S.  N.  17,431.     W.  S.  C,  age  61,  admitted  February  27,  1905. 

Onset  with  pain  in  hip  joints  and  soon  after,  urinary  disturbance.  For 
the  past  year  has  voided  every  three-quarter  to  one  hour  at  night.  No 
hematuria;  no  note  on  catheterism  or  retention.  Has  had  dribbling  at 
times.  Pain  in  bladder  region  before  voiding  and  frequent  vesical  spasms 
during  the  act  of  urination. 

General  examination. — Patient  is  healthy  looking  but  sallow.  Mucous 
membranes  of  good  color.  Chest  and  abdomen  negative.  No  note  on 
glands. 

Rectal  examination. — Prostate  enlarged,  both  right  and  left  lobes  irreg- 
ular, very  hard,  and  nodular.  The  right  lobe  about  oVz  cm.  and  the  left 
about  5  cm.  in  the  long  diameter.  Seminal  vesicles  indurated.  Induration 
running  outward  and  upward  beyond  reach.  Median  grove  practically 
obliterated.  Catheter  shows  residual  urine  of  425  cc.  Bladder  capacity  on 
forced  distention  475  cc.  Urine  cloudy.  Sp.  gr.  1005  to  1018.  No  sugar. 
Slight  traces  of  albumin;  no  casts,  considerable  amount  of  pus. 

Patient  advised  to  use  catheter  regularly  and  under  its  use  his  condition 
was  fairly  comfortable  on  leaving  hospital. 
Vol.  XIV.— 41. 


600  Eugli  H.  Young. 

Case  42. — Carcinoma  of  prostate,  vesicles,  and  trigone.  Duration  12 
years.  Symptoms:  Complete  retention  of  urine.  No  pain  or  hematuria. 
2so  operation. 

No.  905.    J.  C,  age  74,  widowed,  admitted  April  19,  1905. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhcEa. 

Present  illness. — About  12  years  ago  he  noticed  slight  increased  fre- 
quency in  urination.  This  condition  gradually  grew  worse  until  three 
years  ago  he  was  voiding  urine  from  12  to  IS  times  at  night  and  often 
every  15  minutes  during  the  day.  Shortly  afterward  complete  retention 
of  urine  came  on  and  he  has  required  catheterization  since,  being  unable 
to  void  naturally. 

S.  P. — The  patient  catheterizes  himself  five  times  a  day  and  gets  along 
very  comfortably.  He  has  no  pain  in  bladder,  rectum,  perineum,  back, 
or  limbs.  There  is  marked  constipation  and  sexual  powers  have  been 
absent  for  several  years. 

Examination. — The  patient  is  a  thin,  pale-looking  man.  Chest  and 
abdomen:    No  notes  made. 

Rectal. — The  prostate  is  considerably  enlarged,  smooth,  but  very  hard. 
The  seminal  vesicles  on  each  side  are  also  considerably  enlarged  and 
very  hard,  being  continuous  with  the  prostate  below  and  with  each 
other,  forming  an  intravesicular  mass  about  2  cm.  wide.  There  are  no 
nodules,  no  enlarged  glands,  and  the  rectum  is  soft  and  not  adherent. 

Urinalysis. — Slightly  cloudy,  1014,  acid,  no  albumin,  no  sugar,  micro- 
scopically pus  cells,  bacilli  and  no  casts. 

Cyctoscopic. — Small  coude  catheter  passes  with  difficulty,  being  grasped 
along  the  entire  prostatic  urethra.  The  bladder  capacity  is  small,  holding 
only  150  cc.  Retention  of  urine  is  complete.  The  cystoscope  shows  a 
very  slightly  rounded  median  bar  with  very  little  enlargement  of  the 
lateral  lobes.  The  mucous  membrane  covering  the  prostate  is  smooth  and 
only  slightly  inflamed.  The  trigone  is  drawn  up  close  behind  the  median 
bar,  is  considerably  hypertrophied  and  shows  two  peculiar  prominent 
elevations  to  the  inner  side  of  each  ureteral  orifice;  that  on  the  left  side 
being  quite  prominent  and  slightly  nodular.  The  ureteral  orifices  appear 
normal.  The  bladder  is  considerably  trabeculated  and  numerous  small 
cellules  are  seen.  There  is  no  intravesical  tumor.  With  finger  in  rectum 
and  cystoscope  in  urethra,  the  median  portion  of  the  prostate  is  found 
greatly  increased  and  it  is  impossible  to  feel  the  beak  of  the  instrument 
in  the  bladder  owing  to  the  subtrigonal  infiltration.  No  operation  advised. 
To  continue  catheter  life. 

February  2.'f. — Letter.    "  The  patient  is  alive,  but  in  constant  misery." 

Case  43. — Carcinoma  of  prostate,  seminal  vesicles,  and  pelvic  glands. 
Duration  four  years.  Frequency  of  urination.  Catheterism.  No  pain, 
no  hematuria.    No  operation.     Catheter  life. 

No.  647.    R.  W.  P.,  age  73,  married,  admitted  June  15,  1905. 

Onset  four  years  ago  with  difficulty  in  voiding  and  a  frequent  desire 


An  Operation  for  Cancer  of  Prostate.  601 

to  urinate.  There  was  a  gradual  increase  in  the  symptoms  until  about 
one  year  ago  when  he  began  to  use  a  catheter  at  night  and  found  nine 
ounces  of  residual  urine.  For  the  next  few  months  he  used  the  catheter 
twice  a  day,  being  able  to  void  small  amounts  naturally,  but  he  was 
finally  compelled  to  use  a  catheter  every  two  to  three  hours,  having 
lost  the  power  of  voiding  spontaneously,  this  he  has  been  doing  for  the 
past  nine  months.  No  hematuria.  Has  had  piles  for  many  years  and  at 
times  an  aching  pain  in  rectum,  but  this  has  not  been  increased  by 
his  prostatic  trouble. 

*S.  P. — Catheterism.  No  pain  except  when  the  desire  to  urinate  comes 
on,  relieved  by  catheter.  Has  lost  no  weight  for  the  past  few  months. 
General  condition  has  improved. 

Examination. — A  thin,  emaciated  old  man.  Lips  of  fair  color.  Chest 
and  abdomen  negative. 

Urine  pale,  acid.    Sp.  gr.  1005  bacilli.    Pus.     Slight  trace  of  albumin. 

Rectal. — The  prostate  is  very  greatly  enlarged,  bulging  far  into  the 
rectum,  and  about  the  size  of  a  medium-sized  orange.  The  left  lobe  is 
apparently  a  little  larger  than  the  right.  The  median  furrow  and  notch 
are  obliterated.  The  seminal  vesicles  are  drawn  down  and  are  adherent 
to  the  upper  end  of  the  prostatic  lobe  on  each  side,  and  the  left  one  is 
particularly  prominent  and  somewhat  indurated  where  it  joins  the  prostate, 
but  a  little  further  up  it  is  soft.  The  right  seminal  vesicle  is  as  large  as 
normal  and  somewhat  difficult  to  palpate.  Two  cord  like  masses  are  appar- 
ent, one  of  which  may  be  the  vas  deferens,  but  another  more  prominent  one 
is  felt  apparently  between  the  outside  of  the  vesicle  running  in  a  direction 
upward  and  outward.  It  is  impossible  to  say  definitely  what  this  is 
(an  indurated  lymphatic?).  The  surface  of  the  prostate  is  generally  smooth, 
but  on  pressure  a  somewhat  nodular  condition  is  noticed.  This  is  due 
possibly  to  soft  areas  between  areas  of  considerable  induration.  The 
prostate  is  very  close  to  the  rectum,  but  the  mucous  membrane  is  movable 
over  it.  Beneath  the  mucous  membrane  of  the  rectum,  but  apparently  in 
the  wall  of  the  rectum  there  are  felt  several  small  bird-shot  like  masses 
over  the  region  of  the  left  lobe  of  the  prostate.  No  definite  peri-prostatic 
glands  are  to  be  felt.     Enlarged  hard  glands  are  present  in  both  groins. 

Cystoscopic  examination. — The  prostatic  orifice  shows  a  distinct  but 
small  median  lobe  with  practically  no  sulcus  between  it  and  the  right 
lateral  lobe  and  a  very  shallow  sulcus  between  iz  and  the  left  lateral  lobe. 
The  lateral  lobes  are  hardly  at  all  intravesically  enlarged  and  there  is 
no  cleft  between  them.  The  surface  of  the  prostate  is  everywhere  smooth. 
With  the  finger  in  the  rectum  and  cystoscope  in  the  urethra  it  is  impossible 
to  feel  the  beak.  There  is  a  large  mass  between  the  two  and  the  upper 
edge  is  very  sharply  outlined  and  declivitous.  A  note  made  at  the  time 
says,  "  carcinoma  suspected,  but  further  examination  required."  Some 
days  later,  by  rectal  examination  under  ether,  the  prostate  and  seminal 
vesicles  were  found  as  described  before,  but  on  examining  the  posterior 
wall  of  the  rectum  a  large  mass  of  glands  matted  together  and  considerably 


603  •  Hugli  H.  Young. 

enlarged  "was  found  lying  between  the  rectum  and  the  sacrum  so  high 
up  that  under  ether  it  was  difficult  for  the  finger  to  get  above  them. 
Between  this  mass  of  glands  in  the  right  seminal  vesicle  a  line  of 
indurated  lymphatics  could  be  felt.  The  diagnosis  of  carcinoma  seemed 
unquestionable.  The  patient  was  discharged  and  advised  to  use  the 
catheter.  Six  months  later  patient  reports  that  his  health  is  greatly  im- 
proved, but  the  urinary  condition  remains  about  the  same — is  obliged  to 
use  catheter  every  two  or  three  hours  night  and  day. 

May  1,  1906. — The  patient  reports  that  until  recently  he  was  very  com- 
fortable. Of  late  he  has  been  suffering  with  considerable  pain  in  rectum 
and  thighs.    He  is  still  leading  a  catheter  life. 

Case  44. — Carcinoma  of  prostate,  seminal  vesicles,  and  pelvic  glands. 
Duration  ttvo  years.  Complete  retention,  catheter  life.  Very  little  pain 
and  blood.    No  operation. 

No.  1106.    W.  W.  S.,  age  65,  married,  admitted  November  25,  1905. 

Complaint. — "  Prostatic  trouble." 

Gonorrhoea  in  1866,  mild  case,  no  gleet  nor  stricture  following. 

Present  illness  began  about  two  years  ago  with  slight  difficulty  of  urin- 
ation. This  condition  has  gradually  grown  worse  and  one  year  ago  the 
patient  was  arising  three  times  at  night  to  urinate.  In  December,  1904, 
he  began  to  have  pain  in  the  end  of  the  penis  during  urination,  and 
slight  hematuria.  In  January,  1905,  he  suffered  severely  from  difficulty  and 
frequency  of  urination,  and  he  consulted  an  advertising  specialist  to  whom 
he  paid  $300  in  advance  for  a  "  cure."  He  was  treated  by  instrumentation, 
prostatic  massage,  grew  rapidly  worse,  and  had  complete  retention  of  urine 
for  the  first  time  on  February  1,  1905.  Since  then  he  has  used  a  catheter 
every  three  to  five  hours,  has  been  unable  to  void,  and  has  frequently 
suffered  a  severe  spasmodic  pain  in  the  bladder,  coming  on  when  it  be- 
comes full,  and  particularly  severe  when  the  last  urine  is  withdrawn. 
There  has  been  no  pain  in  penis,  rectum,  perineum,  thighs,  nor  back. 
There  has  been  no  hematuria  except  that  noted  above.  Sexual  desire  is 
still  present,  but  he  had  no  erections  for  18  months.  He  has  lost  20  pounds 
during  the  past  year. 

8.  P. — The  patient  catheterizes  himself  about  every  five  hours;  is  never 
able  to  void  naturally.  He  suffers  no  pain  except  when  the  bladder 
becomes  full  and  after  catheterization  is  comfortable  for  four  or  five  hours. 
He  suffers  considerably  from  constipation,  often  strains  at  stool,  and  has 
pain  afterwards. 

Examination. — The  patient  is  a  healthy-looking  man  with  lips  of  good 
color,  pulse  of  good  volume  and  regular,  very  slight  arterio-sclerosis. 
Chest  and  abdomen  not  examined. 

Genitalia. — The  right  testicle  is  absent  having  been  removed  on  account 
of  some  "  growth  "  eight  years  ago.  The  left  testicle  and  epididymis  are 
both  normal  and  there  are  no  enlarged  glands  in  either  groin. 

Rectal. — The  prostate,  seminal  vesicles,  and  intravesicular  space  are 
involved  in  an  extensive  indurated  mass.     The  lobes  of  the  prostate  are 


An  Operation  for  Cancer  of  Prostate.  603 

considerably  enlarged  and  bulge  markedly  towards  the  rectum,  are  irreg- 
ular in  surface  with  numerous  small  prominent  nodules.  The  membranous 
urethra  is  enlarged,  hard  and  tender,  and  the  bulb  also  feels  indurated. 
The  prostate  lies  very  close  to  the  triangular  ligament,  is  firmly  fixed,  only 
slightly  tender  on  pressure. 

The  region  of  the  seminal  vesicles  is  replaced  by  an  extensive  mass  of 
induration  continuous  with  the  prostate  and  extending  upward  and  out- 
ward along  the  lateral  wall  of  the  pelvis  to  which  it  is  adherent  on  each 
side.  The  invasion  is  more  extensive  on  the  left  side  passing  beyond 
the  reach  of  the  finger.  On  the  right  side  the  upper  portion  of  the  seminal 
vesicle  is  soft,  but  an  indurated  lymphatic  is  felt  beyond  it  along  the 
wall  of  the  pelvis.  A  broad  indurated  plateau  with  concave  upper  border 
connects  the  seminal  vesicles  above  the  prostate.  Enlarged  glands  and 
lymphatics  are  present  on  both  sides,  but  none  are  made  out  in  the  sacral 
fossa.  The  rectal  mucosa  is  soft  and  movable,  but  the  musculosa  seems 
to  be  adherent  to  the  prostate.  The  induration  in  both  prostate  and 
seminal  vesicles  is  of  very  great  degree. 

Instrumental. — A  coude  catheter  meets  obstruction  at  the  apex  of  the 
prostate.  A  small  soft  rubber  catheter  passes  with  ease.  Retention  of 
urine  is  complete,  bladder  somewhat  contracted.  The  cystoscope  could 
not  be  passed  owing  to  obstruction  near  the  apex  of  the  prostate.  The 
prostatic  secretion  is  alkaline  and  contains  numerous  white  masses  whiclt 
under  the  microscope  are  found  to  be  composed  of  epithelium.  Stained 
specimen  adds  no  further  information.  Numerous  pus  and  granule  cells 
are  present. 

Diagnosis. — Carcinoma  of  the  prostate  and  seminal  vesicles.  Operation 
not  advised. 

April  16,  1906. — Letter.  "  About  a  month  after  leaving  you  the  slight 
bloody  mucous  discharge  stopped.  Catheterization  has  been  necessary 
every  four  to  six  hours.  There  is  considerable  pain  on  inserting  the 
catheter  in  the  deep  urethra.  Hemorrhage  has  been  present  only  once. 
There  has  been  a  gain  in  weight,  no  constipation,  no  rectal  trouble  and 
no  operation.  General  health  and  appetite  are  good.  Sleep  well.  No  pain 
except  when  using  the  catheter.  I  am  better,  suffer  less  and  am  more 
comfortable  than  at  any  time." 

Case  45. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  one 
year.  Acute  gonorrhoea  six  weeks.  Complete  retention  of  urine.  No 
pain,  no  Mood.    No  operation.     Catheter  for  a  time. 

No.  1133.    R.  J.  T.,  age  76,  widowed,  admitted  January  5,  1906. 

Complaint. — "  Enlarged  prostate,  complete  retention  of  urine,  acute  gon- 
orrhoea."    He  had  never  had  gonorrhoea  previously. 

Present  illness  began  about  one  year  ago  with  frequency  of  urination, 
the  patient  having  to  arise  two  or  three  times  at  night  to  urinate.  There 
was  also  difficulty  in  voiding,  but  no  pain  nor  hematuria.  During  the  fall 
of  1905,  urination  was  somewhat  frequent  and  difficult,  the  intervals  being 
about  every  three  hours,  but  there  was  no  pain  and  no  hematuria.    About 


604 


Hugh  H.  Young. 


November  20,  1905,  he  acquired  gonorrhoea  and  was  treated  by  methylene 
blue  internally.  Urination  soon  became  difficult  and  on  December  1, 
complete  retention  of  urine  came  on  and  he  was  catheterized.  Since  then 
he  has  been  catheterized  twice  daily,  the  urethral  discharge  has  continued, 
gonococci  have  been  found  several  times,  he  has  had  no  pain  except  when 
the  bladder  becomes  full.  He  has  lost  no  weight  and  has  had  no  pain  in 
the  back,  rectum,  thighs,  or  legs. 

Status  'prcEsens. — There  is  a  profuse  urethral  discharge,  but  very  little 
irritation  in  the  urethra  or  bladder,  and  no  pain  except  when  the  bladder 
becomes  full.  Retention  of  urine  is  complete  and  the  patient  is  cathet- 
erized two  or  thre  times  daily.    His  general  health  is  excellent. 

Examination. — The  patient  is  a  strong  healthy-looking  man.  Chest  and 
abdomen,  no  notes  made. 

Genitalia. — There  is  a  profuse  urethral  discharge  which  microscopically 
is  found  to  be  composed  of  pus  cells  and  numerous  intracellular  biscuit- 
shaped  diplococci  which  decolorize  by  Gram  and  are  evidently  gonococci. 
There  are  no  enlarged  glands  in  the  groin. 


Fig.   20. — Prostate  and  region  of  seminal  vesicles. 


Rectal. — The  prostate  is  considerably  enlarged,  smooth,  hard.  The  right 
lobe  is  very  prominent  and  extremely  hard.  The  region  of  the  seminal 
vesicles  and  the  intervesicular  space  is  occupied  by  a  broad  hard  mass 
of  induration  as  shown  in  the  accompanying  diagram.  (See  Fig.  20.)  This 
induration  extends  upward  and  outward  along  the  wall  of  the  pelvis  to 
which  it  is  closely  adherent.  It  is  continuous  with  the  indurated  prostate 
below  and  extends  beyond  the  reach  of  the  finger. 

On  the  right  side  a  markedly  indurated  lymphatic  is  felt,  and  on  the  left 
side  two  similar  cords,  as  shown  in  the  diagram.  The  prostate  is  not 
tender,  there  are  no  areas  of  fluctuation,  nothing  to  suggest  acute  prostatic 
infection.  It  is  evident  that  the  gonorrhoea  has  not  acutely  involved  the 
prostate. 

Remark. — Carcinoma  of  the  prostate  was  at  once  suspected.  The  patient 
was  given  injections  of  one-half  per  cent  protargol,  and  was  instructed  to 
inject  some  of  this  into  the  bladder  after  catheterization. 

On  January  10,  he  began  to  void  naturally,  the  discharge  had  decreased 
considerably  and  the  infection  markedly,  but  few  gonococci  were  still 
present. 


An  Operation  for  Cancer  of  Prostate.  605 

On  January  11,  the  patient  was  voiding  naturally,  but  frequently,  a 
catheter  found  640  cc.  residual  urine. 

Gystoscopic  examination. — The  urethra  was  thoroughly  irrigated  before 
instrumentation.  The  bladder  was  difficult  to  wash  clean  owing  to  consid- 
erable pus  being  present.  The  cystoscope  entered  easily  and  showed  a 
slight  rounded  median  bar.  The  lateral  lobes  were  hardly  at  all  enlarged 
and  there  was  no  cleft  between  them  in  front.  There  were  also  no  clefts 
on  either  side  of  the  slight  median  lobe.  The  ureters  were  plainly  visible, 
and  there  was  no  evidence  of  subtrigonal  infiltration  to  be  seen.  The 
bladder  was  trabeculated  and  inflamed,  but  not  ulcerated  and  there  was 
no  vesical  tumor  present.  With  finger  in  rectum  and  cystoscope  in  urethra 
it  was  impossible  to  feel  the  beak  owing  to  a  considerable  mass  of  tissue 
between  it  and  the  rectum  in  the  intravesicular  space.  The  posterior 
commissure  of  the  prostate  was  also  greatly  thickened  so  that  it  was  im- 
possible to  feel  the  shaft  of  the  instrument.  The  induration  was  very 
marked  and  the  picture  was  typical  of  carcinoma. 

January  12,  1906. — The  patient  has  again  required  catheterization.  There 
is  a  profuse  urethral  discharge,  but  no  gonococci  are  found.  The  patient 
is  discharged  at  his  request  with  instructions  to  continue  use  of  protargol 
and  catheterize  himself  when  necessary. 

April  9,  1906. — Letter  from  physician.  "  Since  February  1,  the  patient 
has  not  required  catheterization,  and  he  has  voided  urine  normally.  He 
now  is  enjoying  good  health,  passes  urine  regularly  without  a  catheter 
and  suffers  no  inconvenience  whatever." 

Case  46. — Carcinoma  of  prostate  and  seminal  vesicles..  Duration  of 
prostatic  symptoms  four  years.  Frequency  of  urination,  occasional  reten- 
tion, severe  pain  in  urethra,  perineum,  rectum,  and  thighs.  No  operation. 
Catheter  advised. 

S.  B.  S.,  age  74,  married,  admitted  March  29,  1906. 

Complaint. — "  Enlarged  prostate." 

No  history  of  gonorrhoea. 

Present  illness  began  three  or  four  years  ago  with  difficulty  in  starting 
the  flow  of  urine  and  straining.  This  was  especially  marked  in  the 
morning.  There  was  no  pain  or  burning  in  passing  urine,  no  difficulty  in 
stopping  the  flow  and  no  dribbling.  The  condition  as  above  described 
persisted  without  any  noticeable  change  until  six  weeks  ago,  previous 
to  this  he  voided  urine  only  once  or  twice  during  the  night,  had  never 
had  hematuria  nor  pain  in  the  rectum  or  thighs.  Six  weeks  ago  acute 
retention  of  urine  came  on  requiring  catheterization.  Since  then  he  has 
been  able  to  void  urine  occasionally  in  small  amounts,  but  has  used  the 
catheter  from  one  to  four  times  every  day.  The  residual  urine  has  gener- 
ally been  between  three  and  four  ounces.  He  has  suffered  considerable 
pain,  paroxysmal  in  character,  coming  on  with  attempts  to  void  and 
situated  in  the  perineum  and  thence  radiating  to  the  glans  penis.  He 
has  also  had  an  intense  pain  in  the  rectum,  and  down  the  left  thigh 
and  leg.    A  dull  aching  pain  has  been  present  across  the  sacrum.    He  has 


606  Hugli  H.  Young. 

never  had  hematuria,  has  not  passed  gravel,  has  lost  15  pounds  in  weight 
and  considerable  strength. 

Sexual  powers.- -No  note  made. 

Status  prcBsens. — Micturition  difficult,  frequent  often  every  hour.  Cath- 
eterization occasionally  necessary.  Residual  urine  generally  between  three 
and  four  ounces.  Severe  pain  in  urethra,  perineum,  rectum,  and  thighs, 
dull  pain  in  back,  sacral  region. 

Examination. — The  patient  is  fairly  well  nourished,  lips  of  fair  color. 
The  chest  is  barrel-shaped  and  very  hyperresonant  and  expiration  is 
prolonged.  The  heart  is  slightly  enlarged,  and  its  beat  is  very  irregular. 
The  abdomen  is  negative.  Genitalia. — There  is  a  small  cyst  of  the  epidid- 
ymis on  the  left  side  and  an  incomplete  inguinal  hernia  on  the  right. 

Rectal. — The  prostate  is  considerably  enlarged,  particularly  on  the 
right  side.  The  surface  is  smooth,  but  the  consistence  is  markedly  in- 
durated there  being  no  soft  areas.  The  induration  extends  far  upward  on 
the  right  side  forming  a  large  mass  in  the  region  of  the  right  seminal 
vesicle  closely  adherent  to  the  pelvic  wall  and  extending  back  beyond  the 
the  reach  of  the  finger.  On  the  surface  of  this  mass  several  indurated 
cords  are  felt.  The  region  of  the  left  seminal  vesicle  is  also  invaded  by 
induration,  but  to  a  less  extent  than  on  the  right  side.  A  considerable 
intravesicular  plateau  of  induration  with  a  sharp  concave  upper  edge  is 
present.  No  enlarged  glands  are  to  be  made  out.  The  prostate  is  markedly 
fixed  in  the  pelvis,  the  rectum  is  soft  and  not  adherent. 

Remark. — The  diagnosis  of  carcinoma  was  evident,  and  as  the  patient 
was  able  to  use  the  catheter  comfortably,  no  operation  was  advised  and 
cystoscopic  examination  was  not  performed. 

I.     Catheter  ISTot  Used,  18  Cases. 

In  18  cases  no  history  of  the  use  of  a  catheter  before  or  after  opera- 
tion has  been  obtained,  but  in  four  cases  it  has  been  impossible  to  get 
word  from  the  patient.  Nine  cases  have  been  heard  from  and  are 
still  alive.  Three  of  these  patients  suffer  from  incontinence  of  urine. 
In  one  case  (Case  60)  there  is  no  difficulty  or  frequency  of  urination 
and  the  only  symptom  is  swelling  of  the  leg  and  thigh  due  to  pressure 
of  the  tumor,  which  is  very  large.  One  patient  (Case  54)  has  im- 
proved considerably  since  his  discharge  from  the  hospital  10  months 
ago,  and  he  now  voids  urine  with  very  little  difficulty  and  pain,  and 
another  patient  (Case  56^)  reports  that  urination  is  natural.  Most  of 
these  patients  suffer  considerably  from  pain  in  the  rectum,  back  or 
thighs,  and  in  some  cases  it  is  very  severe.  In  two  cases  (Cases  60  and 
62)  there  is  little  or  no  pain. 

It  is  interesting  to  note  that  so  large  a  percentage  of  these  cases  of 
carcinoma  of  the  prostate,  at  least  20%  are  able  to  get  along  very 


An  Operation  for  Cancer  of  Prostate.  607 

well  -without  a  catheter  and  in  some  cases  without  any  urinaTy  dis- 
turbance whatever  even  up  to  the  time  of  death.  The  histories  of 
these  cases  are  as  follows : 

Case  47. — Carcinoma  of  prostate.  Metastatic  tumor  of  tiUa,  diagnosed, 
sarcoma  and  amputation  of  thigh  performed.  Little  urinary  trouble. 
Death.    Autopsy. 

S.  N.  4642.     W.  B.  M.,  age  74,  married,  admitted  September  24,  1895. 

Gonorrhoea  several  times  in  youth. 

Onset  with  frequency  of  urination  six  years  ago.  Has  never  had  any 
pain.  About  one  month  ago  had  complete  retention  and  had  to  be  cathe- 
terized.  Since  then  has  used  the  catheter  regularly  about  three  times  a 
day.  Occasionally  voids  voluntarily.  A  note  made  at  this  time  states 
that  prostate  gland  is  very  hard  and  enlarged. 

In  February,  1897,  patient  was  readmitted  for  a  painful  swelling  of 
the  right  tibia  of  three  months'  duration,  beginning  about  7  cm.  above  in- 
ternal malleolus  and  involving  shaft  for  a  distance  of  3%  cm.  Had  some 
dribbling  of  urine  at  this  time,  and  voided  about  every  two  hours,  but 
apparently  was  not  using  a  catheter.  The  tumor  of  tibia  was  diagnosed 
sarcoma  and  amputation  performed  by  Dr.  Halsted.  A  note  on  prostate 
made  at  this  time  states  that  it  was  "  greatly  enlarged,  irregular,  hard, 
nodular — may  possibly  be  a  new  growth  in  region  of  prostate."  At  this 
time  pain  in  hips  and  legs  was  complained  of. 

In  July,  1897,  patient  was  cachectic  and  had  lost  a  great  deal  of  flesh. 
Could  retain  his  urine  five  hours  and  had  no  difficulty  in  voiding.  Suffered 
considerable  pain  in  the  right  hip  and  in  the  shoulders  and  back.  Had 
no  urinary  trouble  or  symptoms  of  enlarged  prostate  at  this  time.  Patient 
died  in  September,  1897. 

Autopsy. — Prostate  is  very  much  enlarged  and  adherent  to  surrounding 
structures  posteriorly;  elsewhere  it  is  sharply  circumscribed.  The  tissues 
at  the  upper  end  cannot  be  differentiated  from  one  another,  and  no  distinct 
pelvic  lymphatic  glands  are  to  be  seen,  everything  being  matted  in  a 
firm,  fibrous  mass.  The  glands  along  the  vertebrae  do  not  show  metastases. 
The  second,  third  and  fourth  lumbar  vertebras,  the  second  rib  and  the  ilium 
are  the  bones  showing  greatest  evidence  of  disease.  The  bladder  wall  is 
not  infiltrated  by  carcinoma.  In  the  tissue  posterior  to  the  prostate  is  a 
tumor  filling  the  blood  vessels  and  invading  the  structures  surrounding 
them.  One  enlarged  bronchial  lymph  gland  next  the  bifurcation  of  the 
trachea  shows  a  carcinomatous  metastases. 

Abdominal  viscera  not  involved. 

Microscopic  examination.—Sections  from  the  prostate,  bones  and  bron- 
chial lymph  glands  present  a  type  of  growth  similar  in  all.  Areas  of  a 
tubular  adenomatous  form  alternate  with  conglomerate  masses  of  cells 
which  have  lost  their  arrangement  in  tubules.  There  is  very  little  stroma 
between  the  tubules,  cells  of  a  cylindrical  shape  project  into  them,. 
meeting  one   another   in   the   mid   line.     The   cells   are  often  vacuolated. 


608  Hugh  H.  Young. 

and  the  nuclei  are  round  and  deep  staining.  In  the  areas  of  carcinoma 
solidum  the  picture  often  suggests  that  of  round  celled  infiltration  or 
lymphoid  nodules,  the  cells  having  lost  their  usual  shape  and  the  nuclei 
staining  deeply  and  regularly.  The  carcinoma  is  of  a  mixed  type,  tubular 
adenocarcinoma  and  carcinoma  solidum. 

Case  48. — Carcinoma  of  prostate  and  vesicles.    No  operation. 

S.  No.  8744.     J.  V.  J.,  age  60,  widowed,  admitted  March  13,  1899. 

No  history  of  gonorrhoea. 

Onset  one  year  ago  with  a  slight  pain  in  right  testicle,  radiating  to 
the  right  iliacal  region.  This  pain  has  gradually  grown  worse.  Six 
months  ago  he  began  to  have  difiiculty  in  retaining  urine  and  some 
frequency  of  micturition. 

S.  P. — Pain  as  above  noted;  frequency  of  urination,  twice  during  the 
day,  and  about  every  hour  at  night;  precipitancy.  No  pain  on  urination. 
No  note  as  to  hematuria,  retention  or  catheterism. 

General  examination. — Rather  poorly  nourished  man.  Mucous  mem- 
branes pale.  Chest  unimportant.  Abdomen  negative,  except  for  some 
tenderness  over  the  symphysis  pubis. 

Glands. — Deep  down  in  the  iliac  region  a  definite  mass  of  enlarged 
glands  is  to  be  made  out.  The  glands  in  each  groin  are  considerably 
enlarged,  as  are  the  axillary  and  epitrochlear.  There  is  a  hydrocele  pres- 
ent on  the  right  side. 

Rectal. — In  the  region  of  the  prostate  is  a  very  hard  tumor,  consisting 
apparently  of  two  spheres,  of  which  the  right  is  much  the  larger,  and 
adherent  to  the  lateral  pelvic  wall.  Between  the  two  there  is  a  deep 
groove  in  which  the  finger  can  be  laid.  The  left  lobe  is  somewhat  lower 
than  the  right,  about  3  cm.  in  diameter,  can  be  completely  encircled  by 
the  finger,  is  smooth  in  outline  and  perfectly  round.  The  right  lobe  is 
more  than  double  the  size  of  the  left,  the  surface  is  also  smooth  and 
rounded.  Both  lobes  are  hard  and  unyielding  and  both  project  well  into 
the  rectum. 

Urine. — Cloudy.  Sp.  gr.  1020,  slight  amount  of  albumin,  numerous  pus 
cells.  The  pain  in  the  right  iliac  region  was  of  such  a  severe  character, 
and  there  being  no  doubt  as  to  the  malignant  character  of  the  prostate, 
patient  was  given  morphia.  In  the  right  iliac  region  large  glands  were 
easily  palpable  deep  down,  and  they  were  very  sensitive  to  pressure.  No 
operation  advised. 

Case  49. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration,  eight 
months.    Frequency  of  urination,  constipation,  dull  pain  in  the  bladder. 

S.  N.  9441.     J.  M.,  age  57,  married,  admitted  September  20,  1899. 

Gonorrhoea  twice  in  youth. 

Onset  eight  months  ago,  with  intermittent  pain  in  bladder  and  increased 
frequency  of  urination.  Urination  has  gradually  increased  until  he  is 
voiding  six  to  eight  times  at  night,  and  of  late  has  had  some  dribbling. 


An  Operation  for  Cancer  of  Prostate.  609 

has  lost  40  to  50  pounds  during  the  last  two  months  and  has  grown  much 
weaker.  Has  been  jaundiced  and  vomited  frequently.  Has  never  had 
complete  retention. 

Status  prasens.— Frequency  of  urination  with  slight  incontinence; 
considerable  straining  on  voiding,  no  hematuria,  no  history  of  complete 
retention  or  catheterization.  Considerable  failure  in  general  health.  A 
dull  pain  in  the  bladder  region  is  present.  Bowels  constipated,  but  no 
pain  on  defecation. 

Examination. — A  rather  poorly  nourished  man;  looks  somewhat  anemic. 
Chest  negative. 

Abdomen.— The  bladder  is  greatly  distended,  reaching  above  the  umbili- 
cus. There  is  a  slight  glandular  enlargement  in  both  groins,  no  other 
enlargement  noted. 

Rectal. — The  prostate  is  very  large,  filling  anterior  half  of  pelvic  out- 
let. It  is  uneven  in  contour,  nodular,  and  bound  down  on  the  left  side. 
On  the  left  side  low  down  there  is  a  distinct  nodule  on  the  surface; 
notch  cannot  be  palpated.  No  cystoscopic  note.  Diagnosis  of  carcinoma 
evident. 

Urine  fairly  clear.  Sp.  gr.  1020,  no  sugar,  trace  of  albumin,  some  pus. 
Operation  not  advised. 

Case  50. — Carcinoma  of  prostate,  seminal  vesicles  and  base  of  bladder. 
Duration,  two  years.  Symptoms:  Frequency  of  urination,  hemorrhage 
and  pain.    No  operation. 

S.  N.  11,479.     R.  M.  C,  age  60,  admitted  January  28,  1901. 

Onset  with  an  attack  of  strangury,  elevation  of  temperature,  pain  at 
neck  of  bladder,  bloody  urine,  pain  and  tenesmus  after  urination.  The 
attack  gradually  subsided,  but  the  patient  did  not  entirely  recover  health 
and  strength  for  one  year.  After  that  he  felt  fairly  well  until  six  weeks 
ago,  when  he  noticed  blood  in  urine,  slight  pain  after  urination,  aching 
at  neck  of  bladder.  He  now  gets  up  to  void  about  twice  at  night,  stream 
free  and  never  interrupted.  Has  had  a  glycosuria  from  10  to  15  years. 
Some  history  of  calculi  passed  several  years  ago,  but  no  renal  colic.  No 
important  loss  of  weight. 

General  examination. — Well  nourished;  lips  somewhat  pale;  no  glandu- 
lar enlargement.  Chest  and  abdomen  apparently  negative.  Catheter  shows 
a  residual  of  15  cc.  and  bladder  capacity  of  250  cc. 

Cystoscopic  examination  shows  a  general  cystitis.  In  the  region  of 
the  left  ureter,  about  an  inch  from  it  on  the  left  lateral  wall  a  small 
polypus  about  the  size  of  a  toothpick,  the  length  about  IVz  cm.,  the  outer 
end  frayed  out,  is  seen.  On  account  of  hemorrhage  thorough  study  of 
bladder  was  not  obtained.  A  further  cystoscopic  examination  three  weeks 
later  showed  that  behind  the  urethral  orifice  the  mucous  membrane  was 
much  corrugated,  irregular  and  swollen  and  about  half  way  between  the 
prostatic  orifice  and  the  point  where  the  right  ureter  should  be,  a  de- 
pressed ulcer  was  visible.     In  the  region  of  the  right  ureter  the  mucous 


610  Hugh  H.  Young. 

membrane  was  rough,  granular  and  the  ureteral  orifice  could  not  be 
made  out  with  certainty.  The  left  ureter  was  seen  in  an  elevated  ridge 
and  between  it  and  the  other  ureter  the  trigone  was  much  changed,  ele- 
vated, rough  and  granular.  The  prostate  orifice  was  rough,  but  did  not 
give  the  appearance  of  a  hypertrophied  prostate. 

Rectal  examination  revealed  an  irregular  indurated  condition  at  the 
upper  end  of  the  prostate,  the  outlines  of  which  were  obscured,  the  indu- 
ration probably  involving  the  bladder  and  the  seminal  vesicles.  There 
was  no  definite  enlargement  of  the  prostate,  but  the  feeling  on  palpation 
combined  with  the  cystoscopic  picture  suggested  malignancy,  although 
nothing  positive  could  be  said  except  that  an  ulcer  existed  in  the  trigone, 
surrounded  by  a  much  swollen,  corrugated,  elevated,  granular  mucous 
membrane.    No  papillomatous  or  cauliflower  growth  present. 

Urine. — Reddish,  1020,  acid,  slight  sugar;  heavy  ring  of  albumin;  micro- 
scopically, much  blood  and  pus. 

April  18,  1906. — Letter  from  physician.  "  The  patient  has  been  dead  for 
two  years." 

Case  51. — Carcinoma  of  prostate,  seminal  vesicles  and  bladder.  Dura- 
tion, eight  months.  Symptoms:  Pain,  hematuria,  loss  of  weight.  No 
operation.    No  catheter. 

S.  N.  15,288.     C.  H.  D.,  age  64,  admitted  October  8,  1903. 

Gonorrhoea  at  15  years  of  age. 

For  the  past  20  years  an  indefinite  history  of  obscure  bladder  trouble 
characterized  by  an  occasional  attack  of  frequency  of  urination,  some 
burning,  at  times  a  little  blood  in  the  urine;  eight  months  ago  frequency 
and  burning  became  more  marked  and  urine  bloody.  About  the  same 
time  began  to  suffer  with  pain  in  the  lower  right  side,  which  seemed  to 
have  its  origin  in  the  region  of  the  perineum  and  right  testicle  and  to 
descend  along  the  cord  as  high  as  the  umbilicus.  In  May,  1903,  cystoscopic 
examination  was  performed  by  Dr.  Cabot,  of  Boston,  who  found  a  small 
ulcer  to  the  left  of  the  right  ureter.  The  prostate  was  very  slightly 
enlarged  at  the  time,  but  the  seminal  vesicles,  cord  and  testicles  were 
negative.  The  paroxysms  of  pain  in  the  right  side  gradually  increased 
in  intensity  and  apparently  had  no  connection  with  urination — he  would 
have  several  attacks  in  the  course  of  a  day.  During  the  course  of  the 
last  months  these  pains  have  radiated  down  the  right  thigh  into  the 
foot  and  sole.  The  urine  at  this  time  and  for  some  months  previously 
has  contained  pus  and  blood. 

-S.  P. — Severe  pains  as  above  noted,  which  require  %  gr.  of  morphia 
daily;  loss  of  strength;  about  12  pounds  in  weight  in  the  last  six  months. 
Urinary  disturbance  is  not  very  marked  and  apparently  causing  but  little 
trouble  in  comparison  to  the  pains  referred  to  above. 

Examination. — Spare,  sallow  man.  Mucous  membranes  of  fair  color. 
Abdomen  negative  except  that  in  both  iliac  fossa  and  above  symphysis 
there  is  a  considerable  tenderness.  One  or  two  glands  just  palpable  in 
right  groin. 


An  Operation  for  Cancer  of  Prostate.  611 

Rectal  examination. — The  prostate  a  little  larger  than  normal.  The  right 
lobe  is  quite  indurated  and  extends  upward  and  is  continuous  with  the 
seminal  vesicle,  the  lower  part  of  which  is  indurated.  Left  seminal  vesicle 
is  not  indurated,  and  left  side  of  prostate  also  not  indurated.  A  very 
small  amount  of  bloody  residual  urine  is  present. 

Cystoscopic  examination  not  very  satisfactory,  but  a  large  intravesical 
tumor,  which  is  apparently  on  the  right  side  of  the  bladder,  is  easily 
seen.  It  is  close  to  prostatic  orifice  and  apparently  springs  from  the 
trigone.     It  is  impossible  to  study  the  prostatic  orifice. 

April  16,  1906. — Letter  from  physician.  "  After  returning  home  the 
course  of  the  disease  was  characterized  by  progressive  emaciation  until 
death  ensued  January  16,  1904.  Urination  was  not  more  difficult,  and  cathe- 
terization was  never  necessary.  For  a  month  before  death  he  had  slight 
incontinence.  There  was  considerable  pain,  and  persistent  constipation. 
No  operation  was  necessary." 

Case  52. — Carcinoma  of  prostate,  seminal  vesicles  and  Madder,  icith 
an  extensive  intravesical  tumor.  Duration  of  symptoms,  eight  months 
Burning  on  urination,  hematuria,  pain  in  liack  and  thigh.  No  operation. 
Death  tcithin  two  years. 

No.  502.     D.  H.  F.,  age  45,  married,  admitted  November  26,  1903. 

Complaint. — "  Hematuria." 

Gonorrhcea  20  years  ago,  no  sequelae. 

Present  illness  began  eight  months  ago  with  a  severe  burning  in  the 
urethra,  which  was  present  all  day  up  to  2  o'clock  in  the  afternoon  and 
then  disappeared,  only  to  come  again  the  next  day.  This  continued  for 
four  days.  A  little  later  urination  became  more  frequent  and  the  burning 
in  the  urethra  returned.  In  May,  1903,  he  was  voiding  urine  10  to  12 
times  during  the  day  and  once  at  night,  and  there  was  pain  in  the  right 
groin,  and  extending  into  the  region  of  the  appendix.  In  July  hematuria 
first  appeared,  but  continued  slight  for  the  next  six  weeks.  About  two 
months  ago  he  had  a  severe  attack  of  pain  in  the  region  of  the  left  kidney, 
which  radiated  down  the  left  ureter;  was  very  acute  in  character,  and 
passed  off  after  the  passage  of  a  large  amount  of  blood  in  the  urine.  Since 
then  patient  has  had  six  similar  attacks,  and  the  urine  has  been  constantly 
stained  with  blood,  at  times  very  red.  His  general  health  has  remained 
good  and  he  has  gained  in  weight. 

Status  prcesens. — Urination  once  at  night,  and  at  about  normal  intervals 
during  the  day.     Urine  always  cloudy.     General  health  excellent. 

Examination. — The  patient  looks  well,  and  his  lips  are  of  good  color. 
Chest — no  note  made.  Abdomen — negative,  with  exception  of  slight  ten- 
derness in  the  right  side  on  deep  palpation.  No  definite  enlargement  of 
the  kidney  is  to  be  made  out. 

Rectal. — The  prostate  is  very  little  larger  than  normal,  but  is  markedly 
indurated,  nodular,  and  very  tender.  Both  seminal  vesicles  are  enlarged 
and  indurated,  and  continuous  with  the  prostatic  induration,  the  right 
vesicle  being  the  larger. 


612  Hugli  H.  Young. 

Gystoscopic. — A  catheter  passes  with  ease  and  finds  very  little  residual 
urine.  The  cystoscope  shows  a  slight  enlargement  of  the  median  por- 
tion of  the  prostate.  The  left  half  of  the  bladder  and  ureteral  orifice  are 
normal  in  appearance.  The  right  half  of  the  bladder  is  the  site  of  an 
irregular  tumor  growth  which  surrounds  the  orifice  of  the  right  ureter, 
and  extends  backward  and  outward  along  the  lateral  wall  of  the  bladder, 
and  forward  to  a  point  just  behind  the  prostatic  orifice,  but  separated 
from  it  by  a  small  area  of  normal  mucous  membrane.  The  surface  of 
the  tumor  is  papillomatous  in  type,  in  places  shaggy  and  cauliflower  like, 
in  others  villous,  and  in  others  smoothly  lobulated.  Several  ulcerated 
areas  are  seen,  the  wall  of  the  bladder  apparently  being  involved. 

With  finger  in  rectum  and  cystoscope  in  urethra  the  vesical  tumor  is 
apparently  continuous  with  the  indurated  vesical  beneath. 

Diagnosis. — Carcinoma  of  prostate  and  seminal  vesicles,  with  involve- 
ment of  bladder  and  intravesical  tumor.     Operation  not  advised. 

March  11,  1905. — Letter.  "  The  patient  died  January  12,  1905.  Hematuria 
had  been  intermittent  and  never  very  severe,  but  urination  was  always 
very  painful,  and  he  suffered  excruciating  pain,  particularly  during  the 
last  six  weeks,  during  which  he  had  shooting  pains  in  the  right  leg.  The 
inguinal  glands  became  involved  and  there  seemed  to  be  som^  involve- 
ment of  the  bones  at  the  right  iliac  synchondrosis.  The  lymphatics  of 
the  right  spermatic  cord  and  of  the  penis  were  obstructed,  and  a  small 
ulcer  developed  on  the  glans  penis." 

Case  53. — Carcinoma  of  prostate,  seminal  vesicles  and  pelvic  glands. 
Duration,  four  years.  Pain  in  urethra.  No  hematuria.  No  operation 
advised. 

No.  985.     W.  J.  B.,  age  70,  widowed,  admitted  July  8,  1905. 

Complaint. — "  Bladder   trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  four  years  ago  with  irritation  at  the  neck  of 
the  bladder  during  and  at  the  end  of  urination.  There  was  no  difficulty 
and  no  frequency  of  urination,  no  pain  nor  hemorrhage.  The  irritation 
disappeared  after  drinking  mineral  waters,  but  returned  six  months  later, 
and  has  continued  up  to  the  present  time.  Three  years  ago  the  patient 
had  to  get  up  at  night  to  urinate  for  the  first  time.  Pain  began  18  months 
ago;  first  in  the  suprapubic  region,  dull  in  character  and  relieved  by  urina- 
tion. Since  then  the  pain  has  gradually  increased,  but  has  not  involved 
any  other  region.  He  has  never  passed  blood  and  has  only  lost  10  pounds. 
Has  never  had  complete  retention  of  urine. 

S-  P- — Urine  is  voided  about  15  times  daily.  Micturition  is  difficult 
and  accompanied  by  straining  and  the  stream  is  small.  During  urination 
there  is  a  pain  beginning  at  the  neck  of  the  bladder  and  extending  down 
to  the  end  of  the  penis;  it  is  severe  in  character.  There  is  also  a  dull 
aching,  deep-seated  pain  in  the  suprapubic  region,  which  comes  on  as 
the  bladder  becomes  full  and  is  relieved  by  urination.  He  has  had  no 
pain  in  rectum,  perineum,  thighs,  groins  or  testicles;  no  hematuria,  and 
has  never  been  catheterized. 


An  Operation  for  Cancer  of  Prostate.  613 

Examination. — The  patient  is  sparely  built,  lips  are  pale,  pulse  regular 
and  of  good  volume.  The  glands  in  both  axillae,  groins  and  iliac  regions 
are  palpable  and  enlarged. 

Genitalia. — The  left  epididymis  is  indurated. 

Rectal. — The  prostate  is  greatly  enlarged,  particularly  the  right  lateral 
lobe,  the  surface  of  which  is  very  irregular  and  hard,  the  nodules  being 
of  very  great  induration.  The  left  lateral  lobe  is  smooth  and  only  slightly 
enlarged,  and  in  its  anterior  two-thirds  is  soft.  Near  its  upper  end,  how- 
ever, it  is  indurated  and  slightly  irregular.  The  left  seminal  vesicle  and 
vas  deferens  are  distinctly  palpable  and  slightly  indurated,  as  shown 
in  Fig.  21.  The  region  of  the  right  seminal  vesicle  and  vas  deferens  are 
occupied  by  an  irregular,  hard  mass,  which  is  continuous  with  the  prostate, 
and  extends  upward   and  outward  along  the   lateral  wall  of  the  pelvis. 

A  few  glands  are  to  be  felt  along  the  left  side  of  the  pelvis.  The  right 
side  and  the  sacral  fossa  are  negative.  The  prostatic  mass  is  firmly  fixed 
in  its  position,  but  is  not  tender.  The  rectum  is  closely  adherent  but  not 
ulcerated. 


Fig.  21. — Outlines  of  induration  in  region  of  prostate,  seminal  vesicles 
and  intervesicular  space  in  Case  No.  53. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  95  cc.  residual 
urine.  The  bladder  is  small  and  irritable,  retaining  only  90  cc.  of  fluid. 
The  cystoscope  enters  easily  and  shows  a  slight  intravesical  enlargement 
of  the  right  lateral  lobe  with  a  peculiar  irregular  lobulated  outgrowth 
covered  by  smooth  mucous  membrane,  as  shown  in  the  cystoscopic  pic- 
tures (see  Case  XXIX,  "Cystoscopy  of  the  Prostate").  The  median  bar 
is  light  and  there  is  no  enlargement  of  the  left  lateral  lobe.  The  bladder 
is  markedly  trabeculated  and  inflamed,  but  there  is  no  evidence  of  neo- 
plasm. The  ureteral  orifices  are  normal  in  location  and  appearance. 
With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  is  felt  some- 
what to  the  left  of  the  median  line,  the  tissues  between  the  rectum  and 
trigone  being  but  very  little  thickened.  To  the  right  of  the  beak,  how- 
ever, a  considerably  indurated  mass  is  to  be  felt,  and  the  median  portion 
of  the  prostate  is  greatly  thickened  and  moderately  indurated. 

The  prostatic  secretion  contains  very  few  lecithin  cells.  Several  masses, 
apparently  plugs  of  the  prostatic  ducts,  were  examined  microscopically  and 
were  found  to  be  composed  almost  entirely  of  epithelial  cells  of  a  coarsely 
granular  character.  Numerous  large  and  small  granule  cells,  free,  were 
seen.     A  considerable  number  of  polynuclear  cells  were  present. 


614  Eugli  E.  Young. 

Case  54. — Carcinoma  of  the  prostate  and  left  seminal  vesicle.  Large 
intravesical  lobes,  one  villous  in  type.  Duration,  four  years.  Frequency 
of  urination,  pain,  no  hematuria.    No  operation.    No  catheter. 

No.  1014.     D.  A.,  age  57,  married,  admitted  July  27,  1905. 

The  patient  had  gonorrhoea  several  times  20  years  ago,  no  gleet  or 
stricture  following. 

The  present  illness  began  in  August,  1901,  with  frequent  urination  and 
burning  in  the  perineum;  this  gradually  increased  and  on  May  13,  1902, 
he  was  admitted  to  the  hospital.  At  that  time  he  urinated  20  to  30  times 
every  night,  and  micturition  was  slightly  difficult,  particularly  at  the 
beginning,  and  urine  occasionally  contained  blood.  He  was  not  constipated 
and  had  no  pain  or  tenesmus  on  defecation.  There  had  been  no  loss  or 
weight. 

Examination  at  that  time  showed  a  well  nourished  man.  A  soft  rubber 
catheter  passed  easily,  there  was  no  residual  urine  present,  the  bladder 
capacity  was  610  cc.  "^Tiile  in  the  hospital  he  voided  urine  normally,  there 
was  no  residual  urine,  the  "  prostate  was  not  enlarged  " — evidently  a  case 
of  irritable  prostate.  The  patient  was  discharged  without  further  treat- 
ment. 

Second  admission  July  21,  1905. — The  patient  returned  complaining  of 
difficulty  and  frequency  of  urination.  He  says  that  after  leaving  the 
hospital  he  vs;^s  comfortable  for  a  year  and  then  the  trouble  started  up 
anew.  During  the  past  year  he  has  had  hematuria  about  once  a  week, 
generally  associated  with  pain  in  the  lower  abdomen.  At  present  he 
voids  urine  eight  or  ten  times  during  the  night,  and  very  frequently 
during  the  daytime,  and  there  is  considerable  burning  during  urination. 
He  is  quite  constipated.     He  has  kept  at  work  up  to  the  present  time. 

Examination. — Patient  is  well  nourished,  with  lips  of  good  color.  The 
heart  and  lungs  are  negative.  The  abdomen  is  slightly  distended  and 
there  is  dullness  5  or  6  cm.  above  the  pubes  and  in  the  median  line,  but 
no  mass  is  felt.  There  is  no  (Edema  of  the  extremities  (no  note  as  to 
glands  of  groin). 

Rectal. — The  prostate  is  considerably  enlarged,  smooth  and  with  a 
rather  flat  posterior  surface.  It  is  soft  in  the  median  part,  but  firm 
along  the  lateral  edges,  but  the  induration  is  nowhere  of  stony  hardness. 
The  induration  extends  upward  on  either  side  into  the  region  of  the 
seminal  vesicles  as  far  as  the  finger  can  reach  and  several  enlarged  glands 
are  felt  along  the  left  lateral  wall  of  the  pelvis.  In  this  region  three 
small  glands  are  to  be  felt.  The  median  furrow  is  deep  and  the  notch 
is  obliterated,  but  no  definite  intravesicular  mass  is  to  be  made  out. 

Cystoscopic. — Catheter  passes  with  ease  and  finds  about  50  cc.  residual 
urine.  The  cystoscope  shows  considerable  intravesical  enlargement  of 
the  prostate  with  a  deep  sulcus  anterior  and  posterior,  and  large  bulging 
lateral  lobes,  the  left  of  which  is  the  largest,  has  an  irregular  surface 
covered  with  shaggy,  white  villi,  and  has  the  typical  appearance  of  vesical 
neoplasm.     Near  the  urethra  this   lobe   is   covered   with   smooth  mucous 


An  Operation  for  Cancer  of  Prostate.  615 

membrane.  The  right  lobe  is  smooth  and  the  mucous  membrane  appears 
to  be  normal.  The  bladder  is  apparently  not  involved  by  the  neoplasm. 
The  ureters  cannot  be  seen. 

Urinalysis. — Cloudy,  acid,  1018,  albumin  in  small  amount.  Microscopi- 
cally, considerable  pus;   occasionally  red  blood  corpuscles. 

The  diagnosis  of  carcinoma  of  the  prostate  was  made.  No  operation 
performed. 

April  10,  1906.— Ijetter.  "  After  leaving  the  hospital  I  passed  considerable 
blood  at  times.  Catheterization  has  not  been  necessary.  Urination  has 
been  moderately  difficult,  but  associated  with  considerable  pain.  At 
present  I  am  improved.  I  have  only  a  slight  pain  when  voiding  urine, 
do  not  use  the  catheter,  there  is  no  blood.  I  have  only  lost  one  pound  in 
weight." 

Case  55. — Carcinoma  of  prostate  and  seminal  vesicles  and  pelvis  glands. 
Duration,  two  years.  Pain,  frequency  of  urination,  TiemorrTiage,  loss  of 
tceight.    No  operation.    No  catheterism. 

No.  1037.     H.  S.,  age  65,  married,  admitted  September  15,  1905. 

Complaint. — "  Dribbling  of  urine." 

No  history  of  gonorrhoea  or  previous  urinary  trouble. 

Present  illness  began  about  two  years  ago,  with  frequency  of  urination, 
which  has  gradually  grown  worse.  Four  months  ago  he  began  to  have 
diflBculty  in  voiding  and  for  the  past  two  months  he  has'^had  .continuous 
dribbling.  About  two  years  ago,  but  before  frequency  of  urination  de- 
veloped, he  began  to  have  pain  in  the  penis,  testicles,  back  and  hips,  of  a 
dull,  constant  character.  During  the  past  year  he  has  also  had  pain 
down  the  left  thigh,  legs,  and  foot,  and  of  late  has  had  pain  in  the  back 
of  the  right  thigh.  There  has  been  very  little  pain  associated  with  urina- 
tion, no  pain  at  the  end,  nor  in  the  bladder.  One  and  a  half  years  ago 
he  passed  blood  for  the  first  time,  but  had  no  further  hemorrhage  until 
four  months  ago.  Sexual  powers  were  normal  up  to  two  years  ago,  but 
he  has  had  no  erections  since  then.  He  has  not  lost  weight,  but  has  be- 
come weaker. 

Status  prcesens. — Continuous  dribbling  of  urine.  More  or  less  constant 
pain  in  penis,  testicles,  back,  both  thighs,  left  leg  and  foot.  No  pain  dur- 
ing urination  nor  in  the  urethra  nor  bladder. 

Examination. — The  patient  is  emaciated  and  pale.  There  is  considerable 
arterio-sclerosis.  Chest  and  abdomen  are  negative.  The  genitalia  are 
negative,  except  for  a  slight  tenderness  in  the  left  epididymis.  The  right 
inguinal  glands  are  palpable,  but  very  little  enlarged. 

Rectal. — The  prostate  is  very  large,  projecting  far  towards  the  rectum, 
markedly  indurated,  the  induration  extending  upward  and  involving  the 
seminal  vesicles.  On  the  right  side  a  hard,  rounded  cord  extends 
upward  beyond  the  upper  end  of  the  seminal  vesicle  along  the  lateral  wall 
of  the  pelvis,  and  on  the  left  side  several  large  indurated  cords  are  felt, 
which  extend  beyond  the  sacro  sciatic  notch  and  are  accompanied  by 
shot-like  glands.  An  intravesicular  plateau  of  induration  is  felt  above 
Vol.  XIV.— 42. 


616  Eugli  E.  Young. 

the  prostate.  The  surface  of  the  prostate  and  vesicles  is  irregular  and 
very  hard,  but  only  slightly  tender.  A  few  hard  glands  are  to  be  felt  in 
the  sacral  fossa,  but  none  along  the  right  lateral  wall  of  the  pelvis.  The 
left  lobe  of  the  prostate  and  left  seminal  vesicle  are  distinctly  larger 
than  the  right.  The  mucous  membrane  of  the  rectum  is  close  to  the 
prostate,  but  is  apparently  not  adherent. 

Cystoscopic. — A  catheter  passes  with  ease  and  finds  only  50  cc.  residual 
urine.  The  bladder  capacity  is  contracted,  holding  only  100  cc.  The 
cystoscope  shows  a  considerable  irregular  outgrowth  of  the  prostate  all 
around  the  orifice  with  very  shallow  clefts  in  front.  The  median  and 
lateral  portions  of  the  prostate  are  about  equally  enlarged,  and  all  are  of 
moderate  degree.  The  mucous  membrane  covering  the  prostatic  outgrowth 
is  irregular,  in  places  deeply  fissured,  but  nowhere  ulcerated  or  villous 
in  type.  The  trigone  and  ureters  are  concealed  behind  the  median  en- 
largement of  the  prostate.  The  bladder  is  trabeculated  and  inflamed, 
but  apparently  not  invaded.  With  finger  in  rectum  and  cystoscope  in 
urethra  there  is  a  great  increase  in  the  subtrigonal  and  suburethral  tissues 
so  that  the  beak  cannot  be  felt.     No  operation  advised. 

May  1,  1906. — Report  by  daughter.  "  The  patient  has  not  been  catheter- 
ized  since  leaving  the  hospital,  but  has  had  continual  incontinence  and  has 
worn  a  urinal.  He  has  had  no  pain  in  the  bladder  or  urethra,  no  difiiculty 
of  urination  and  no  hematuria.  About  once  a  week  he  has  had  an  attack 
of  very  severe  pain  which  starts  in  the  back,  on  the  right  side,  and 
radiates  thence  down  the  back  of  the  right  thigh  to  the  toe.  The 
severe  pain  continues  for  about  five  minutes  and  recurs  several  times 
during  a  period  of  24  to  48  hours,  during  which  time  there  is  a  dull  pain 
in  the  back  on  the  right  side.  He  has  never  had  any  pain  in  the  left  back, 
thigh  or  leg.     There  is  no  difficulty  in  voiding  urine." 

Case  56. — Carcinoma  of  prostate,  seminal  vesicles  and  trigone.  Duration 
two  and  a  half  years.  Symptoms:  Hematuria,  frequency,  pain.  Xo  opera- 
tion. 

No.  1040.     T.  E.  D.,  age  56,  admitted  September  23,  1905. 

Complaint. — "  Bladder  and  kidney  trouble." 

Gonorrhoea  twice,  when  about  30  years  of  age;  was  apparently  perfectly 
cured. 

Present  illness  began  two  and  a  half  years  ago,  with  frequent  passage  of 
blood  before  urination,  but  not  associated  with  pain.  In  November,  1904, 
the  patient  became  unconscious  and  remained  so  for  two  weeks,  and 
after  that  he  was  never  able  to  work  on  account  of  weakness.  Until 
April,  1905,  there  was  no  pain  or  urinary  disturbance.  The  patient  then 
began  to  have  pain  in  the  rectum,  worse  after  stool,  and  pain  at  the  end 
of  urination,  located  in  the  end  of  the  penis.  Since  then  urination  has 
been  more  frequent,  and  of  late  there  has  been  pain  in  the  perineal 
region  and  frequently  in  the  rectum,  occasionally  radiating  to  the  buttocks. 
He  has  had  no  pain  in  back,  hips,  legs,  testicles  nor  abdomen.  He  has 
lost  40  pounds. 


An  Operatio7i  for  Cancer  of  Prostate.  617 

^-  P- — Urination  four  or  five  times  during  the  night  and  the  same 
number  during  the  day.  Pain  in  the  end  of  the  penis  before  and  after 
urination,  occasionally  pain  in  the  perineum  and  rectum.     No  hematuria. 

Examination. — The  patient  is  a  fairly  well  nourished  man.  Chest  and 
abdomen — no  note   made. 

Rectal — The  prostate  is  very  little  larger  than  normal,  but  at  the  upper 
end  of  the  right  lateral  lobe  a  peculiar,  oval,  indurated  mass,  which 
extends  upward  and  outward  into  the  region  of  the  seminal  vesicle  for 
a  distance  of  3  cm.  is  felt.  Its  upper  end  is  sharply  defined,  rounded,  and 
to  its  inner  side  is  an  indurated  cord  which  extends  upward  and  outward 
beyond  the  reach  of  the  finger,  and  is  taken  for  the  vas  deferens.  The 
left  seminal  vesicle  is  palpable  and  apparently  normal.  The  prostate 
is  indurated,  but  not  of  stony  hardness.  The  surface  is  a  little  irregular, 
particularly  in  the  region  of  the  right  lateral  lobe,  which  is  more  tender 


Fig.  22.     Case  56. 

than  the  left.  There  is  practically  no  intervesicular  mass  and  the  bladder 
feels  soft.  No  enlarged  glands  are  to  be  felt  along  the  lateral  walls  of 
the  pelvis  nor  in  the  sacral  fossa.  The  rectal  mucosa  is  soft,  freely 
movable,  and  there  is  no  periprostatic  induration.  The  accompanying 
diagram  (Fig.  22)  shows  the  shape  of  the  prostate  and  indurated  vesicle. 
The  prostatic  secretion  contains  numerous  micrococci. 

Urinalysis. — Urine  almost  clear,  1022,  acid,  no  albumin,  no  sugar.  Micro- 
scopically, a  few  pus  cells,  a  few  round  squamous  epithelial  cells. 

Gystoscopic. — A  coude  catheter  passes  with  ease  and  finds  90  cc.  residual 
urine.  The  bladder  capacity  is  large.  Study  of  the  prostatic  orifice  shows 
only  a  slight  enlargement  of  the  median  portion  of  the  prostate  which 
is  somewhat  irregular  but  covered  with  smooth  mucous  membrane.  The 
lateral  lobes  are  not  enlarged  and  there  are  no  sulci  present.  Behind  the 
median  portion  of  the  prostate  the  trigone  is  elevated  by  rounded  mass 
about  2  cm.  in  diameter,  and  covered  by  smooth  mucous  membrane.  This 
elevation  lies  in  front  of  the  interureteral  ligament,  being  separated  from 
it  by  a  fairly  deep  pouch.  The  ureteral  orifices  are  situated  in  hyper- 
trophied    ridges,    but    otherwise    normal.     The    bladder    wall    is    slightly 


618  Ilugli  H.  Young. 

trabeculated,  but  not  inflamed.  With  finger  in  rectum  and  cystoscope  in 
urethra  the  beak  can  be  felt  with  ease,  the  tissues  beneath  the  trigone 
do  not  seem  to  be  thickened  in  the  median  line.  To  the  right  of  the 
beak  the  oval  indurated  mass  in  the  region  of  the  right  seminal  vesicle 
is  felt.  In  the  region  of  the  left  seminal  vesicle  nothing  abnormal  is  made 
out.  The  median  portion  of  the  prostate  is  distinctly  thickened  and  much 
harder  than  normal. 

October  12. — The  patient  has  been  passing  more  blood  for  the  past  few 
days,  but  urination  is  less  difficult  and  less  frequent.  His  only  pain  now 
Is  a  slight,  dull  pain  in  the  lower  back. 

Rectal  examination  shows  an  induration  at  the  base  of  the  left  seminal 
vesicle,  and  a  small  transverse  intravesicular  plateau  of  induration  as 
shown  in  the  accompanying  diagram.  It  is  easy  to  pass  beyond  the 
indurated  areas,  but  one  or  two  cords  are  felt  on  the  right  side.  No 
indurated  glands  are  to  be  felt  along  the  lateral  walls  of  the  pelvis  and 
sacral  fossa. 

Diagnosis. — Carcinoma  of  the  prostate  and  seminal  vesicles,  with  in- 
volvement of  trigone.     No  operation. 

April  10,  1906. — Letter.  "  After  returning  home  the  course  of  the  disease 
was  about  the  same  as  before,  viz.:  difficulty  of  urination,  pain  in  the 
rectum,  hematuria  about  once  a  month,  generally  continuing  for  about 
;a  week,  constipation.  No  other  operation  has  been  performed.  At  present 
the  patient  is  worse,  suffers  more  pain,  but  urination  is  natural,  but 
very  frequent  both  day  and  night.     The  catheter  is  not  used." 

Case  BT .—Carcinoma  of  prostate,  vesicles,  membranous  urethra.  Dura- 
tion five  months.    Frequency  and  pain.    No  operation. 

No.  1111.    J.  W.  R.,  age  68,  married,  admitted  December  3,  1905. 

Complaint. — "  Prostatic  trouble.     Frequency  and  difficulty  of  urination." 

No  history  of  gonorrhoea. 

Present  illness  began  five  months  ago  with  frequency  and  difficulty  of 
urination.  For  one  year  previous  to  this  he  had  gotten  up  twice  at  night 
to  urinate,  but  there  was  no  obstruction  and  no  pain.  During  the  past 
five  months  there  has  been  only  a  slight  increase  in  the  difficulty  and 
frequency  of  urination,  but  there  has  been  considerable  pain  which  comes 
on  when  the  bladder  becomes  full,  and  is  quite  sharp  during  urination,  but 
disappears  after  it.  The  pain  is  referred  to  the  end  of  the  penis.  He  has 
had  no  pain  in  the  bladder,  perineum,  deep  urethra,  rectum,  thighs,  hips, 
or  abdomen.    He  has  lost  10  pounds  in  the  past  six  months. 

8.  P. — Micturition  five  times  during  the  night  and  four  times  during  the 
day.  At  times  the  stream  is  almost  normal  in  size,  at  others  it  is  small, 
and  occasionally  there  is  a  slight  dribbling.  When  the  bladder  becomes 
full  he  has  an  urgent  desire  to  urinate  associated  with  pain,  and  during 
urination  he  has  pain  in  the  end  of  the  penis.  Between  urinations  he  is 
comfortable.  He  has  never  had  retention  of  urine  nor  been  catheterized. 
His  bowels  move  regularly  without  difficulty  and  without  pain. 


An  Operation  for  Cancer  of  Prostate.  619 

Examination. — The  patient  is  fairly  well  nourished,  but  is  pale  and  looks 
badly.     Chest  and  abdomen,  no  note  made. 

Genitalia. — The  right  testicle  lies  in  the  external  inguinal  ring  and  is 
small.  The  glands  in  the  groins  are  not  enlarged  and  the  deep  iliac  glands 
are  not  palpable  nor  are  the  epitrochlears,  axillaries  or  cervicals.  On  the 
left  side  deep  palpati9n  reveals  an  indurated  mass  along  the  brim  of  the 
pelvis  which  is  distinctly  painful. 

Rectal. — The  prostate  is  considerably  enlarged,  particularly  on  the  right, 
irregular  with  sharp  lateral  borders.  The  median  furrow  is  present,  notch 
is  obliterated,  the  consistence  is  very  hard  and  quite  tender.  The  anterior 
portion  of  the  prostate  is  very  close  to  the  triangular  ligament,  the 
membranous  urethra  is  large  and  hard.  The  right  seminal  vesicle  is  re- 
placed by  a  mass  of  indurated  tissue,  on  the  surface  of  which  several  hard 
cords  are  made  out,  extending  upward  and  outward  along  the  lateral  wall 
of  the  pelvis  as  far  as  the  finger  can  reach.  In  the  region  of  the  left 
seminal  vesicle  a  similar  indurated  mass  at  least  one  and  one-half  inches 
broad,  and  also  extending  along  the  pelvic  wall  beyond  the  reach  of  the 
finger,  is  present.  Between  the  two  seminal  vesicles,  and  above  the  prostate 
is  a  broad  plateau  of  induration  with  a  sharp  concave  upper  border.  A 
large  gland  is  felt  on  each  side  of  the  pelvis,  but  nothing  is  made  out  in 
the  sacral  fossa.  The  musculosa  of  the  rectum  is  apparently  closely  ad- 
herent to  the  prostate,  but  the  mucosa  is  smooth  and  movable. 

Gystoscopic. — A  large  coude  catheter  passes  with  ease  meeting  very  little 
obstruction  and  finds  only  30  cc.  residual  urine.  The  bladder  capacity 
is  quite  small,  90  cc.  being  introduced  with  difficulty.  The  cystoscope 
enters  with  ease  and  shows  a  small  but  greatly  trabeculated  bladder. 
The  ureters  and  trigone  cannot  be  seen  owing  to  a  fairly  broad  median 
prostatic  bar  with  a  deep  pouch  behind  it.  The  mucosa  is  everywhere 
smooth  and  there  is  no  evidence  of  neoplastic  growth.  The  lateral  lobes 
of  the  prostate  are  not  intravesically  enlarged,  there  is  no  cleft  between 
them  in  front,  nor  on  either  side  of  the  median  bar.  With  finger  in  rectum 
and  cystoscope  in  urethra  it  is  impossible  to  feel  the  beak  of  the  instrument, 
and  an  extensive  hard  intravesicular  subtrigonal  mass  is  to  be  felt,  and  the 
suburethral  portion  of  the  prostate  is  greatly  increased  in  thickness. 

Urinalysis. — Cloudy,  acid,  1024,  no  albumin,  no  sugar,  no  casts  nor  pus. 
Few  epithelial  cells. 

Diagnosis. — Carcinoma  of  the  prostate  and  seminal  vesicles.  Operation 
not  advised. 

March  22,  1906. — Report  by  daughter.  "  The  patient  has  lost  greatly  in 
flesh.  Has  been  very  sick  and  is  extremely  emaciated  and  weak.  The 
catheter  has  not  been  used,  and  micturition  is  now  very  frequent — about 
every  15  minutes  night  and  day.  There  has  been  no  hematuria.  He  suffers 
considerably  from  great  soreness  in  the  lower  abdomen  and  intermittent 
severe  pain  down  the  left  thigh  and  leg  which  extends  into  the  foot.  He 
also  has  occasionally  severe  pain  in  the  chest  and  throat  and  has  difficulty 
and  pain  in  swallowing.     He  takes  opiates  regularly." 


620  Hugh  H.  Young. 

Case  58. — Carcinoma  of  prostate  and  seminal  vesicles.  Duration  two 
and  one-half  years.  Pain  severe,  urination  frequent.  No  hematuria.  No 
operation. 

No.  1180.  L.  N.,  age  72,  married,  seen  in  consultation  at  Elkins,  W.  Va., 
January  13,  1906. 

Complaint. — "  Pain  in  left  leg,  buttock,  and  hip.  Inability  to  use  left 
leg.    Frequency  of  urination." 

No  history  of  gonorrhoea.    No  previous  urinary  trouble. 

About  two  and  one-half  years  ago  the  left  epididymis  became  swollen 
to  the  size  of  a  walnut.  His  physician  examined  the  prostate  and  found 
it  considerably  enlarged.  There  was  very  little  evidence  of  obstruction 
and  no  symptoms  from  it,  and  the  urine  was  normal.  The  epididymitis 
soon  disappeared  under  treatment. 

About  15  months  ago  the  patient  began  to  have  pain  in  the  left  groin 
and  scrotum,  dull  in  character  and  constantly  present  with  intermittent 
acute  paroxysms.  There  was  no  marked  urinary  difficulty,  no  pain  on 
micturition,  no  hematuria.  During  the  past  year  the  pain  as  above  de- 
scribed has  gradually  increased  and  the  patient  has  grown  considerably 
weaker.  He  was  seen  a  second  time  by  his  physician.  Dr.  Golden,  on 
October  28,  1905.  He  was  then  complaining  of  shooting  pains  down  the 
left  thigh  to  a  point  just  below  the  patella.  These  pains  were  aggravated 
by  extending  or  abducting  the  thigh,  and  he  was  most  comfortable  with 
the  left  thigh  and  leg  drawn  up.  There  was  also  considerable  pain  in 
the  lower  portion  of  the  left  buttock,  and  at  a  point  just  above  the  crest  of 
the  ilium  behind. 

Examination  showed  a  point  of  exquisite  tenderness  on  pressure,  limited 
to  the  tuberosity  of  the  left  ischium,  and  also  a  small  area  over  the  poster- 
ior border  of  the  crest  of  the  left  ileum  near  the  synchrondrosis.  The 
prostate  was  found  to  be  much  larger  than  when  seen  two  years  before, 
hard,  slightly  tender,  but  smooth.  There  was  considerable  frequency  of 
urination,  but  no  pain  in  the  bladder  or  urethra.  A  catheter  was  difficult 
to  introduce  and  withdrew  12  ounces  of  residual  urine.  During  the  past 
three  months  the  condition  of  the  patient  has  remained  about  the  same. 

8.  P. — Micturition  every  one  to  two  hours,  and  often  every  half  hour  at 
night.  Total  amount  in  24  hours,  30  ounces.  Urine  passes  without  much 
difficulty,  but  some  times  he  strains  considerably.  He  has  not  had  complete 
retention.  He  has  no  pain  in  bladder,  penis,  or  rectum,  but  defecation 
is  difficult.  There  is  a  constant  pain  in  the  lower  portion  of  the  left  buttock 
and  in  the  back  of  thigh  and  the  left  groin.  There  is  also  a  slight  pain 
in  the  left  testicle. 

Examination. — The  patient  is  a  thin,  nervous-looking  man.  The  heart 
lungs,  abdomen,  and  genitalia  are  negative.  Enlarged  glands  are  present 
in  both  groins. 

Pressure  upon  the  tuberosity  of  the  left  ischium  causes  exquisite  pain, 
but  there  is  no  pain  in  the  structures  around  it.  Along  the  posterior 
border  of  the  crest  of  the  ilium  near  the  synchrondrosis  there  is  severe 


An  Operation  for  Cancer  of  Prostate.  621 

pain  on  pressure  for  a  distance  of  about  3  cm.  No  other  painful  points 
or  areas  made  out. 

Rectal.~The  prostate  is  moderately  enlarged,  smooth  and  not  tender. 
The  right  lobe  is  only  slightly  indurated,  but  the  left  is  very  hard  and  has 
a  sharp  lateral  border.  The  region  of  the  left  seminal  vesicle  is  occupied 
by  a  broad  area  of  great  induration  continuous  with  the  upper  end  of  the 
prostate,  and  extending  upward  and  outward  along  the  lateral  wall  of  the 
pelvis  to  which  it  is  closely  adherent  as  far  as  the  finger  can  reach. 
The  surface  is  irregular  and  several  hard  cords  are  present.  The  right 
seminal  vesicle  is  also  enlarged  and  indurated,  but  much  less  so  than  the 
left.  An  intravesicular  plateau  of  induration  with  a  concave  upper  border 
is  present.  No  enlarged  glands  are  made  out.  The  rectum  was  apparently 
not  involved.  No  instrumental  examination  of  urethra  and  bladder  was 
made.  His  physician  reported  that  there  was  only  a  small  amount  of 
residual  urine  and  that  catheterization  was  not  necessary,  the  patient 
being  able  to  void  without  much  difficulty.     No  operation  was  advised. 

Ju7ie  1,  1906. — Letter.  "  The  patient  died  about  six  weeks  after  your 
visit.  He  was  treated  by  X-ray  without  benefit  and  continued  to  suffer 
severely  from  pain." 

Case  59. — Carcinoma  of  prostate,  seminal  vesicles,  and  pelvic  glands. 
Duration  two  years.  Frequency,  burning  pain  in  bacTc,  hips  and  thighs. 
No  operation. 

No.  1186.     G.  D.,  age  60,  married,  admitted  January  16,  1906. 

Complaint. — "  Difficulty  of  urination." 

GonorrhcEa  at  age  of  23  years.    No  sequelae. 

Present  illness  began  two  years  ago  with  burning  on  urination  which 
came  on  at  irregular  intervals.  A  little  later  he  suffered  with  pain  in  the 
lumbar  region,  but  under  treatment  both  symptoms  disappeared  for  five 
months.  During  the  past  18  months  he  has  had  repeated  attacks  of  burning 
on  urination,  difficulty  in  voiding,  and  pain  in  the  back,  and  urination 
has  become  steadily  more  frequent.  During  the  past  four  months  he  has 
had  pain  in  the  hips  and  legs.    Sexual  desire  has  been  absent  for  two  years. 

Status  prwsens. — Urination  every  half  hour  during  the  day,  and  from  two 
to  six  times  at  night.  Urine  difficult  to  start,  stream  small,  often  comes  in 
driblets.  Pain  in  the  back,  hips,  and  legs,  and  in  the  bladder  after 
urination;  during  micturition  there  is  a  burning  in  the  urethra.  Has 
lost  10  pounds  and  grown  weaker.  The  pain  is  more  or  less  constant  and 
worse  in  the  right  side  of  back,  and  right  hip.    No  hematuria. 

Examination. — Fairly  well  nourished  man.  Chest  and  abdomen  not 
noted. 

Rectal. — The  prostate  and  seminal  vesicles  are  involved  in  an  indurated 
mass.  The  prostate  is  considerably  enlarged,  irregularly  nodular,  and  of 
stony  hardness.  The  induration  extends  into  the  region  of  the  seminal 
vesicles,  and  on  the  left  side  along  the  pelvic  wall  as  far  back  as  the 
sacrum.  In  the  intravesicular  space  a  plateau  of  marked  induration  is 
present.  Indurated  lymphatic  glands  are  to  be  felt  on  both  sides  of  the 
pelvis  and  in  the  groin. 


632  Hugh  H.  Young. 

Cystoscopic. — A  coude  catheter  passes  with  ease  and  finds  160  cc.  residual 
urine.  The  bladder  capacity  is  340  cc.  The  cystoscope  shows  a  fairly  large 
rounded  median  lobe  with  a  shallow  sulcus  on  either  side  which  projects 
well  into  the  bladder  and  covers  up  the  trigone  so  that  it  is  impossible 
to  see  the  ureters  or  the  interureteral  ligament.  The  lateral  lobes  of  the 
prostate  are  very  little  enlarged  intravesically.  The  mucous  membrane 
covering  the  prostate  is  smooth.  The  bladder  wall  is  slightly  trabeculated. 
There  is  no  intravesical  tumor  or  evidence  of  infiltration  of  the  bladder 
wall.  With  finger  in  rectum  and  cystoscope  in  urethra  the  beak  of  the 
instrument  cannot  be  felt  owing  to  an  extensive  subtrigonal  mass  of  indur- 
ation. The  suburethral  portion  of  the  prostate  is  also  thickened  and 
greatly  indurated. 

Urinalysis. — Clear.  No  albumin,  no  pus,  no  bacteria.  Neither  operation 
nor  catheter  advised. 

Case  60. — Carcinoma  of  the  prostate,  seminal  vesicles,  memManous 
urethra,  pelvic  and  iliac  and  inguinal  glands.  Duration  four  months.  No 
pain,  no  frequency  of  urination,  no  hematuria.  Only  symptom  present 
swelling  of  leg  and  thigh.    No  operation.    No  catheterism. 

P.  R.,  age  58,  married,  admitted  February  9,  1906. 

Complaint. — "  Swelling  of  the  left  leg." 

Gonorrhoea  at  the  age  of  36,  no  sequelae. 

Present  illness  began  four  months  ago  when  he  first  noticed  swelling  of 
the  left  leg.  The  swelling  came  on  suddenly  and  involved  the  right  foot, 
leg,  and  thigh,  and  very  soon  reached  considerable  size,  was  not  ac- 
companied by  pain,  difiiculty  or  frequency  of  urination  or  due  to  any  ascrib- 
able  cause.  This  swelling  has  persisted  up  to  the  present  time,  and  there 
have  been  no  other  symptoms.  He  has  been  arising  twice  at  night  to 
urinate  for  the  past  two  years,  but  micturition  is  free  and  painless  and  has 
never  been  accompanied  by  hematuria.  He  has  lost  10  pounds  in  weight 
during  the  last  four  months,  and  his  general  health  has  failed  somewhat. 

Sexual  powers. — Normal  up  to  four  months  ago,  since  then  no  desire 
and  no  erections. 

Status  prwsens. — The  only  symptom  of  which  the  patient  complains  is  a 
swelling  on  the  left  lower  limb  from  the  hip  to  the  foot,  which  is  increased 
by  standing  and  decreases  after  remaining  in  bed  several  hours.  He  has 
no  pain  in  this  region  nor  in  the  groin.  Urination  is  normal  during  the 
day  and  he  arises  only  twice  at  night  to  void.  There  has  never  been  any 
hematuria;  no  difficulty  of  urination,  no  pain  in  the  bladder,  urethra, 
rectum,  thighs,  hips,  or  back. 

Examination. — The  patient  is  well  nourished,  but  somewhat  pale.  The 
arteries  are  thickened  but  not  nodular.  The  chest  and  abdomen  are 
negative.  In  the  left  groin  is  an  extensive  mass  of  confluent  glands  10  x  7 
cm.  in  size.  They  are  quite  hard  and  immovable  being  firmly  attached  to 
the  deeper  structure.  There  are  no  areas  of  fluctuation,  the  skin  is  not 
adherent  and  is  of  normal  color.  The  left  thigh  and  leg  are  considerably 
swollen,  the  skin  is  of  a  bluish  color.    The  right  thigh  and  leg  are  normal 


An  Operation  for  Cancer  of  Prostate. 


623 


in  size  there  is  no  pitting  on  pressure.  The  scrotum  is  normal  in  appear- 
ance, there  is  no  cedema.  The  testicles,  epididymis,  and  cords  are  normal. 
Rectal. — The  prostate  presents  a  peculiar  irregular  enlargement.  The 
right  lateral  lobe  presents  a  prominent  smooth,  oval  mass  about  the  size 
of  a  hen's  egg  in  its  upper  two-thirds  as  shown  in  Fig.  23.  This  mass  rises 
at  least  3  cm.  above  the  surface  of  the  prostate,  is  tense,  elastic  almost 
fluctuating,  but  is  not  tender.  The  anterior  portion  of  the  right  lobe  is 
not  enlarged,  but  is  distinctly  indurated.  The  right  vesicle  is  slightly 
indurated  and  several  hard  cords  are  felt  on  its  surface,  these  extend 
out  to  the  pelvic  wall.     The  left  lobe  of  the  prostate  is  much  less  prom- 


FiG.  23. — Rectal  chart  with  outlines  of  induration  of  prostate,  vesicles, 
lymphatics  and  pelvic  glands  shown  in  comparison  with  normal  (in 
dotted  lines).     Case  60. 


inent  than  the  right,  but  is  broader,  more  indurated,  very  irregular  and 
nodular.  The  mass  of  induration  extends  much  farther  anteriorly  than  the 
normal  outlines  of  the  prostate,  apparently  involving  the  membranous 
urethra,  and  extending  well  down  towards  the  perineum  to  a  point  just 
beneath  the  skin  as  shown  in  the  accompanying  diagram.  At  the  upper 
end  the  mass  extends  into  and  involves  the  seminal  vesicles  and  structures 
along  the  lateral  wall  of  the  pelvis  to  which  the  prostate  and  seminal 
vesicle  are  markedly  adherent.  With  the  finger  directed  anteriorly,  a  mass 
of  glands,  evidently  the  deep  iliacs,  are  felt,  and  several  indurated  lymphat- 
ics connecting  them  and  the  mass  in  the  lateral  wall  of  the  pelvis  are  made 
out.  The  intravesicular  space  is  very  little  involved,  and  the  bladder  above 
feels  soft. 

No  enlarged  glands  are  palpable  in  the  region  of  the  right  vesicle  or  in 
the  right  lateral  wall  of  the  pelvis.    The  rectal  mucosa  is  soft,  not  adherent. 


624:  Hugh  H.  Young. 

not  ulcerated.  The  axillary  glands  are  palpable  but  soft.  The  epitrochlear 
and  cervical  are  not  palpable. 

Urinalysis. — Clear,  acid,  of  normal  specific  gravity.  Chemically  and 
microscopically  negative. 

Remark. — No  instrumental  examination  of  the  bladder  was  made  because 
the  patient  had  practically  no  difficulty  or  frequency  of  urination  and  no 
pain.  The  diagnosis  of  carcinoma  vpas  positive,  and  cystoscopy  might  have 
produced  traumatism  or  infection.  The  patient  was  advised  to  bandage 
leg  and  to  have  it  massaged.  He  was  followed  for  about  two  months. 
His  only  complaint  was  swelling  of  the  leg  which  was  worse  on  standing 
and  incapacitated  him  for  heavy  work.  He  suffered  no  pain,  no  difficulty, 
no  frequency  of  urination,  no  hematuria. 

May  15,  1906. — The  condition  remains  about  the  same.  He  has  no 
urinary  trouble  and  no  pain.    His  only  complaint  is  swelling  of  the  leg. 

Case  61. — Carcinoma  of  prostate  with  extensive  intravesical  tumor  out- 
growth around  the  urethral  orifice.  Involvement  of  both  seminal  vesicles, 
and  lymphatics.    No  operation. 

S.  No.  18,995.    J.  R.  C,  age  78,  married,  admitted  April  7,  1906. 

Complaint. — "  Bladder  trouble." 

No  history  of  gonorrhoea. 

Present  illness  began  about  six  months  ago  with  involuntary  escape  of 
urine  into  his  clothes.  A  large  amount  of  urine  was  discharged,  there 
was  no  pain  or  other  symptoms.  Examination  of  the  urine  at  that  time 
showed  considerable  pus.  He  was  treated  by  irrigations  through  a  catheter 
with  improvement.  The  course  of  the  disease  has  been  characterized  by 
gradually  increasing  difficulty  and  pain  which  has  become  so  severe  during 
the  past  three  weeks  as  to  be  almost  unbearable.  Of  late  the  urination  has 
been  extremely  difficult,  and  accompanied  by  intense  pain  in  the  rectum, 
bladder,  penis,  and  down  the  thighs  and  legs,  and  lasting  for  several 
minutes  after  urination.  He  has  never  had  hematuria,  complete  retention 
of  urine,  nor  gravel.  He  has  lost  15  pounds  in  weight  and  very  greatly  in 
strength.     Erections  and  sexual  desire  have  been  absent  for  years. 

Status  prccsens. — Almost  constant  dribbling  of  urine  night  and  day. 
Frequent  attempts  at  urination  with  the  passage  of  small  amounts  and 
severe  pain  in  the  bladder,  urethra,  rectum,  and  thighs.  No  sharp  colicky 
pains. 

Examination. — The  patient  is  well  nourished.  There  is  no  evidence  of 
emaciation  or  cachexia.  The  mucous  membranes  are  of  good  color.  The 
chest  is  barrel-shaped,  percussion  hyperresonant,  expiration  prolonged. 
The  heart  is  enlarged,  but  there  are  no  murmurs.  The  abdomen  is  nega- 
tive.    Genitalia  negative. 

Rectal. — There  is  considerable  equilateral  enlargement  of  the  prostate. 
The  surface  is  smooth  and  there  are  no  nodules.  It  is  definitely  but 
slightly  indurated,  but  there  is  no  tenderness.  The  prostate  is  quite  fixed 
to  the  surrounding  structures  of  the  pelvis,  but  the  membranous  urethra 
is  normal.    In  the  region  of  the  right  seminal  vesicle  is  a  mass  of  indura- 


An  Operation  for  Cancer  of  Prostate.  625 

tion  continuous  with  the  prostate,  and  on  the  surface  are  several  indurated 
cords  which  run  outward  toward  the  pelvic  wall  to  which  the  enlarged 
vesicle  is  bound  by  adhesions.  The  left  seminal  vesicle  is  less  indurated 
than  the  right,  but  there  are  several  hard  cords  on  its  surface.  In  the 
intravesicular  region  there  is  a  small  but  definite  mass  of  induration  and 
the  bladder  wall  feels  hard.  The  rectal  mucosa  is  soft  and  not  adherent. 
No  definite  enlarged  glands  are  made  out. 

Cystoscopic. — The  patient  voided  5  cc.  of  cloudy  urine.  A  coude  catheter 
enters  easily  and  finds  50  cc.  residual  urine  and  a  bladder  capacity 
of  60  cc.  The  cystoscope  shows  an  irregular  shaggy  growth  all  around  the 
prostatic  orifice  as  shown  in  the  accompanying  chart,  Pig.  24.  As  seen 
here  .the  surface  is  very  irregular,  in  places  composed  of  villi,  and  in 
others  larger,  irregular,  more  or  less  pedunculated  masses.  No  definite 
smooth  lobes  or  typical  intralobular  clefts  such  as  one  sees  in  prostatic 
hypertrophy   seen.      Study   of   the   bladder    is   very   unsatisfactory    owing 


Fig.  24. — Cystoscopic  chart  showing  irregular  tumor  growth  around 
prostate   orifice.     Case   No.    61. 

to  its  small  size  and  the  presence  of  pus  and  blood.  There  was  no  calculus 
seen,  and  searching  with  the  instrument  failed  to  reveal  any  grating.  With 
finger  in  rectum  and  cystoscope  in  urethra  the  beak  of  the  instrument 
could  not  be  felt  owing  to  marked  increase  in  thickness  in  the  region 
of  the  trigone  and  median  portion  of  the  prostate.  The  suburethral 
portion  of  the  prostate  is  considerably  thicker  and  harder  than  normal. 
The  patient  remained  in  the  hospital  two  days  during  which  time  urine 
was  voided  at  very  frequent  intervals  and  in  very  small  amounts,  10  to 
20  cc.  at  a  time.  There  was  also  almost  constant  dribbling  of  urine.  No 
operation  was  advised. 

Case  62. — Carcinoma  of  prostate,  seminal  vesicles,  and  memtranous 
urethra,  furnishing  only  slight  symptoms.     No  operation:    No  catheterism. 

No.  1263.    A.  A.  L.,  age  59,  widowed,  admitted  April  12,  1906. 

Complaint. — "  Frequent  and  painful  urination." 

Gonorrhoea  at  the  age  of  24 — light  case,  no  gleet  or  stricture  following. 
No  impairment  of  sexual  powers.     Has  been  generally  healthy. 


636  Hugh  H.  Young. 

Present  illness  began  six  months  ago  with  slight  difSculty  and  increased 
frequency  of  urination,  particularly  at  night,  patient  having  to  arise  two  to 
three  times  to  urinate.  Previous  to  that  did  not  arise  more  than  once  at 
night  to  void  and  general  health  was  excellent.  Later  patient  began  to 
have  pain  at  beginning  of  urination  located  in  the  deep  urethra  produced 
by  straining  in  order  to  start  the  flow  of  urine.  During  the  past  six 
months  there  has  been  slight  increase  in  the  difficulty  and  frequency, 
but  there  has  been  no  increase  in  the  pain  and  no  involvement  of  other 
regions.  He  has  not  lost  weight  or  strength  and  his  general  health  is 
good.     Has  never  passed  blood  nor  calculus. 

Six  weeks  ago  consulted  Dr.  Keidel.  At  that  time  he  was  Avoiding  urine 
about  every  two  hours  night  and  day,  urine  was  clear  and  sterile.  Cathet- 
erization was  somewhat  difficult,  silver  catheter  being  finally  used  and 
150  cc.  residual  urine  withdrawn,  bladder  capacity  was  normal.  During 
the  past  six  weeks  he  has  had  occasional  massage,  has  been  catheterized 
twice  with  some  improvement. 

S.  P. — Patient  voids  urine  four  times  during  the  night  and  about  every 
two  to  three  hours  during  the  day.  Urine  difficult  to  start,  and  the  stream 
is  exceedingly  small.  No  terminal  dribbling.  There  is  a  slight  spasmodic 
pain  in  efforts  to  start  flow  of  urine,  but  usually  no  pain  at  end  of  urination, 
no  hematuria.  Has  occasional  dull  aching  pain  in  the  lumbar  region  of 
both  sides,  slight  in  character.  (This  has  been  present  two  to  three 
months.)     Never  any  pain  in  hips,  thighs,  groin,  or  testicles. 

Sexual  powers. — During  the  past  six  months  erections  have  been  very 
infrequent  and  weak,  insufficient  for  coitus. 

Examination. — Patient  is  a  healthy  looking  man.  No  arterio-sclerosis, 
pulse  full  and  regular.  The  abdomen  is  very  fatty  and  pendulous,  making 
examination  unsatisfactory. 

Genitalia. — Left  epididymis  slightly  enlarged  and  indurated.  Right 
testicle  is  rotated,  globus  major  being  below.  The  cord  of  the  vas  deferens 
is  considerably  enlarged  and  indurated  almost  up  to  the  ring. 

Rectal. — Prostate  is  slightly  larger  than  normal,  very  little  increased 
transversely.  Surface  is  smooth,  irregular  and  near  the  apex  of  the  left 
lobe  is  a  prominent  hard  small  nodule.  In  consistence  it  is  considerably 
indurated,  the  induration  extending  forward  along  the  membranous 
urethra.  Prostate  is  very  flxed  being  flrmly  attached  particularly  on  the 
right  side  to  the  adherent  structures  and  to  the  triangular  ligament. 
Extending  upward  on  each  side  in  the  region  of  the  seminal  vesicle  is  an 
indurated  mass  which  is  greatest  on  the  left  side.  On  the  right  side 
several  hard  cords  are  felt  extending  beyond  the  reach  of  the  finger,  and 
running  along  the  lateral  wall  of  the  pelvis.  Between  the  cords,  soft 
tissue  is  felt  "  probably  healthy  seminal  vesicle."  There  are  only  moderate 
adhesions  to  the  pelvic  wall.  In  the  region  of  the  left  seminal  vesicle  are 
several  indurated  cords  which  extend  upward  and  outward  along  the 
lateral  wall  of  the  pelvis  beyond  reach  of  the  finger.  One  indurated  gland 
is  felt  among  them.     Some  soft  tissue  is  felt  beneath  the  cords      There  is 


An  Operation  for  Cancer  of  Prostate.  627 

considerable  induration  along  the  pelvic  wall.  In  the  intravesicular  region 
a  definite  mass  of  moderate  induration  is  made  out.  The  striking  feature 
about  the  case,  is  the  induration  low  down  about  the  membranous  urethra; 
small  size  of  the  prostate  and  presence  of  some  softness  in  the  upper 
portions  of  the  prostate  and  in  the  seminal  vesicles  and  presence  of 
numerous  indurated  cords. 

Cystoscopic. — The  patient  was  placed  on  the  table  for  cystoscopic  exam- 
ination. A  small  coude  catheter  passed  with  ease  but  detected  some  con- 
striction of  the  membranous  and  prostatic  urethra.  There  was  only  a 
small  amount  of  residual  urine  present,  the  bladder  was  somewhat  con- 
tracted. An  attempt  was  made  to  pass  the  cystoscope,  but  it  was  impossible 
to  introduce  it  through  the  membranous  urethra.  Some  hemorrhage  was 
produced  and  it  was  thought  best  to  desist  rather  than  to  produce  too  much 
trauma.    No  treatment  advised. 

Case  63. — Carcinoma  of  prostate,  seminal  vesicle,  pelvic  glands,  and 
viembranous  urethra.  Duration  six  months.  Frequency  of  urination,  pain 
in  hack.    No  operation. 

G.  U.  No.  17,647.     S.  B.,  age  66,  married,  admitted  April  19,  1906. 

Complaint. — "  Frequency  of  urination,  dribbling,  pain." 

Patient  denies  gonorrhoea. 

Present  illness  began  six  months  ago  with  frequency  of  urination.  The 
stream  was  small,  irregular  and  intermittent.  This  gradually  increased 
and  four  months  ago  he  was  voiding  urine  about  every  15  minutes  night 
and  day.  Three  months  ago  he  had  a  sudden  complete  retention  of  urine 
which  lasted  for  24  hours  and  was  relieved  by  a  catheter.  He  has  been  able 
to  void  urine  voluntarily  since,  and  urination  has  been  less  frequent,  but 
he  has  suffered  pain  in  the  back,  both  lumbar  and  sacral  regions  and  in  the 
left  buttock  and  hip.  He  has  lost  considerable  weight  and  is  much  weaker. 
He  has  not  passed  blood  or  gravel.  His  sexual  powers  have  completely 
disappeared. 

Status  prcesens. — Urination  eight  to  ten  times  during  the  day;  two  to 
four  at  night.  Pain  in  back,  left  buttock  and  hip,  and  an  indefinite  feeling 
of  distress  directly  after  urination.  There  is  a  considerable  involuntary 
escape  of  urine.    He  is  weak  and  has  lost  his  nerve. 

Examination. — No  note  as  to  general  examination. 

There  is  no  urethral  discharge.    The  urine  is  cloudy  in  all  three  glasses. 

Rectal. — The  prostate  is  very  much  enlarged,  irregular,  nodular  and  of 
stony  hardness.  The  surface  is  somewhat  flat.  On  both  sides  the  prostate 
extends  to  the  pelvic  wall  to  which  it  is  closely  adherent.  The  induration 
extends  into  the  region  of  both  seminal  vesicles  as  far  as  the  finger  can 
reach  and  there  is  a  large  intravesicular  mass  with  a  hard  nodular 
surface.  Both  vesicles  are  firmly  adherent  to  surrounding  structures  and 
along  the  outer  edge  of  the  left  vesicle  a  number  of  small  indurated  glands 
are  felt.  The  induration  extends  downward  along  the  membranous  urethra 
especially  on  the  right  side.     Glands  are  felt  along  the  pelvic  wall  on  the 


628  ■  Hugh  H.  Young. 

right  side,  in  botli  groins  and  in  the  right  axilla,  and  along  the  left 
vesicle  as  mentioned  above.  There  are  no  glandular  masses  palpable  in 
the  abdomen. 

Case  64. — History   not    obtained.    Autopsy   at    Bay    View.    Large   soft 
prostate  with  peculiar  colloid  metastases. 

The  specimen,  G.  U.  292,  was  obtained  at  autopsy  on  white  male,  age  65, 
by  Dr.  Bunting.  The  prostate  was  symmetrically  enlarged,  the  enlarge- 
ment affecting  chiefly  the  lateral  lobes,  the  gland  was  softer  than  normal 
(at  autopsy).  On  section  the  prostate  is  found  to  have  an  opaque  yellow- 
ish white  medullary  appearance  which  is  quite  uniform  except  at  the 
extreme  periphery  where  the  tissue  is  more  translucent.  At  several  points, 
however,  the  capsule  is  found  invaded  by  the  opaque  tissue.  Beneath  the 
mucosa  of  the  bladder  near  the  urethral  angle  of  the  trigone  are  two  small 
nodules  of  tissue  similar  to  that  of  the  prostate,  the  larger  of  which 
measures  about  5  mm.  in  diameter,  otherwise  the  bladder  appears  normal 
and  its  walls  are  slightly  hypertrophied.  Extending  from  the  posterior 
surface  of  the  prostate  into  the  cellular  tissue  between  it  and  the  rectum 
is  a  mass  of  firm  fibrous  tissue  in  which  are  opaque  whitish  areas,  and  in 
addition,  masses  of  translucent  gelatinous  material.  This  extension 
reached  the  perineum.  Scattered  over  the  peritoneal  surface  generally 
reaching  the  greatest  development  of  the  omentum  the  diaphragm  and 
about  the  spleen  and  tail  of  the  pancreas  and  numerous  similar  gelatinous 
nodules,  varying  in  size  from  a  few  mm.  to  1  or  2  cm.  On  the  diaphragm 
these  form  grape-like  clusters,  gelatinous  materials.  The  organs  in 
general  are  free  from  internal  metastases.  There  is  moderate  dilatation 
of  the  urethra. 

Microscopic  examinaiion. — Sections  from  the  prostate  shows  a  very 
cellular  carcinoma.  It  is  of  the  carcinoma  simplex  type,  occasionally  large 
alveoli  filled  with  cells  polymorphus  in  shape  and  with  a  small  round 
regularly  staining  nucleus  are  seen.  About  these  alveoli  broad  bands  of 
stroma  are  inserted.  The  major  part  of  the  carcinoma  shows  no  distinct' 
alveolar  arrangement,  but  consists  of  a  mass  of  cells  rather  loose,  with 
here  and  there  small  strands  of  fibrous  stroma  interlacing  in  various 
directions.  (See  Fig.  13.)  The  carcinoma  is  extremely  cellular,  and  shows 
a  very  insignificant  amount  of  stroma.  A  fair  sized  vein  whose  walls  are 
lined  with  a  rather  cuboidal  type  of  epithelium  is  noted  in  one  section. 
The  epithelium  which  is  very  irregular  in  shape  and  size  sometimes  occurs 
in  solid  sheets,  and  again  is  broken  up  forming  irregular  open  spaces.  In  a 
few  small  limited  areas  the  carcinoma  assumes  an  adenoma  type.  Sections 
from  metastases  to  the  diaphragm  show  a  complete  colloid  transformation 
of  these  metastases. 

Diagnosis. — Carcinoma  simplex  with  colloid  metastases. 


INDEX 

Carcinoma  of  the  prostate,  Early  diagnosis  and  radical  cure  of,  485. 

Conservative  perineal  prostatectomy,  Treatment  of  prostatic  hypertrophy 
by,  1. 

Early  diagnosis  and  radical  cure  of  carcinoma  of  the  prostate,  485. 

Fistulse,  Recto-urethral,  477. 

Geraghty,  John  T.,  See  Young,  Hugh  H.,  and  Geraghty,  John  T.,  124. 

Prostate,  carcinoma  of  the.  Early  diagnosis  and  radical  cure  of,  485. 

Prostatic  hypertrophy,  by  conservative  perineal  prostatectomy,  Treatment 
of,  1. 

Recto-urethral  fistulae,  477. 

Young,  Hugh  H.,  The  early  diagnosis  and  radical  cure  of  carcinoma  of  the 
prostate,  485;  Recto-urethral  fistulae,  477;  The  treatment  of  prostatic 
hypertrophy  by  conservative  perineal  prostatectomy,  1. 

Young,  Hugh  H.,  and  Geraghty,  John  T.,  Pathology  of  prostate  hyper- 
trophy as  shown  by  a  study  of  120  cases,  124. 


f  ■-  ■■  ■  ■ 


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